Health inspection·March 28, 2025

F 0580 from his appointment. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Order Summary Report (Physician ' s Order) dated 3/24/2025, the Physician ' s Order indicated a STAT CBC was ordered on 3/7/2025 at 8:28 a.m. and reordered at 2:20 p.m. upon Resident 1 ' s return to the facility from paracentesis appointment. Residents Affected - Few During a review of Resident 1 ' s Nursing Progress Notes dated 3/7/2025 and timed at 2:20 p.m., the Nursing Progress Notes indicated Resident 1 returned to the facility after his paracentesis appointment and the lab was called to confirm Resident 1 ' s lab order for a STAT CBC. During a review of the laboratory ' s Dispatch Log dated 3/7/2025, the Dispatch log indicated a phlebotomist (a healthcare professional trained to collect blood samples from patients) attempted to draw Resident 1 ' s blood on 3/7/2025 at 10:09 p.m. but Resident 1 refused. During a review of Resident 1 ' s Nursing Progress Note dated 3/7/2025 on the 3 p.m. to 11 p.m. shift, the Nursing Progress Note indicated there was no documentation that Resident 1 ' s physician or RP were notified when Resident 1 refused to have his blood drawn. During a telephone interview on 3/25/2025 at 11:25 a.m., RP 1 stated she was not notified on 3/7/2025 during the 3 p.m. to 11 p.m. shift when Resident 1 refused to have his blood drawn and stated she should have been notified and allowed to make medical decision for Resident 1. During an interview on 3/20/2025 at 3:31 p.m., Registered Nurse Supervisor (RNS) 2 stated she worked on the 3 p.m., to 11 p.m., shift on 3/7/2025 and received a report from RNS 1, who worked the 7 a.m., to 3 p.m. shift (3/7/2025), that Resident 1 had an order for a STAT CBC. RNS 2 stated she processed the lab order but when the lab technician came to the facility (3/8/2025) Resident 1 refused to have his blood drawn. RNS 2 stated she did not call Resident 1 ' s physician to notify him that Resident 1 refused to have his blood drawn. RNS 2 stated she should have called the physician and Resident 1 ' s RP to notify them of Resident 1 ' s refusal and to allow Resident 1 ' s physician to give instructions for Resident 1 ' s care. During a telephone interview on 3/25/2025 at 1:24 p.m., Resident 1 ' s Physician stated Resident 1 had a GI bleed and had he been notified of Resident 1 ' s refusal to have his blood drawn, he could have reordered another lab or sent Resident 1 to the GACH to be evaluated, instead of waiting. During an interview on 3/26/2025 at 5:13 p.m., the Director of Nursing Services (DON) stated the licensed nursing staff are expected to call the primary physician and the RP to notify them when there is a COC and/or difficulty in completing an order. The DON stated staff should have notified Resident 1 ' s physician as well as his RP when Resident 1 refused to have his blood drawn to prevent a delay in the care of Resident 1. During a review of the facility ' s Policy and Procedure (P/P) titled Resident Rights dated 10/2022, the P/P indicated the facility shall have the residents and their responsible parties be informed of, in advance and participate in, their treatment including changes of plan of care. During a review of the facility ' s P/P titled Change of Condition dated 2016, the P/P indicated the facility shall provide treatment and services to address changes in accordance with the residents ' needs by notifying the physician of the residents ' current status, assessment findings and subsequent actions. The P/P indicated the facility shall notify the resident and /or responsible party of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055041 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Beach Post-Acute 2725 Pacific Avenue Long Beach, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 the resident ' s current status and subsequent actions/orders Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055041 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Beach Post-Acute 2725 Pacific Avenue Long Beach, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly identify and intervene to ensure Resident 1 received treatment and care in accordance with professional standards and their comprehensive person-centered care plan when two physician's orders for Stat (immediately) laboratory (lab) tests were not completed within the required time frame for one of four sampled residents (Resident 1), reviewed for gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum). The physician placed a STAT order for Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body's immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together] when a blood vessel is damaged}, hemoglobin and hematocrit}a measure of the proportion of red blood cells in the total volume of blood}to assess and treat Resident 1's anemia and history of GI bleeding. The first STAT CBC order was completed in 7 hours 49 minutes, which is outside the 4-hour time requirement. The second STAT CBC order was completed in 9 hours and 45 minutes, which is outside the 4-hour time requirement with the results communicated in 12 hours and 32 minutes, which is outside the 6-hour time requirement.The facility failed to: 1. Ensure when Resident 1 refused to have his blood drawn for a laboratory analysis/test (CBC), his physician was notified in order to obtain instructions for Resident 1's care. 2. Ensure the laboratory was provided with an accurate order indicating a STAT priority to prevent a delay in processing of the order and obtaining Resident 1's blood and test results promptly. 3. Ensure staff followed Resident 1's Care Plan that indicated obtain and monitor Resident 1's laboratory test as ordered. 4. Ensure the facility had a system in place to follow up on Resident 1's STAT lab order, in order to obtain STAT lab results promptly, within two to six hours. 5. Ensure staff followed the facility's undated Policy and Procedure (P/P) titled Reporting Laboratory Test Results that indicated emergency STAT lab work should have results in two to six hours 6. Ensure staff followed the facility's P/P titled, Processing Physician Orders dated 8/2017 that indicated the facility shall maintain accuracy of physician orders to provide appropriate care and services related to patient/residents' risks. 7. Ensure staff followed the facility's P/P titled Change of Condition dated 2016 that indicated the facility shall provide treatment and services to address changes in accordance with the residents' needs These deficient practices had the potential for hemorrhage, hypovolemic shock, and death from blood loss. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including GI bleed and anemia. During a review Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 1 was unable to make decisions for himself that were consistent and reasonable. During a review of Resident 1's Care Plan on anemia dated 2/18/2025, the Care Plan indicated a goal for Resident 1 was to maintain his laboratory values within acceptable parameters and to be free from signs/symptom (s/s), and complications of anemia with interventions that included observing, documenting, and reporting to Resident 1's physician any s/s of fatigue, dizziness, change in cognition, paleness, low hemoglobin, obtain and monitor laboratory work as ordered, report the results to Resident 1's physician and follow up as indicated. During a review of Resident 1's COC dated 3/5/2025 and timed at 5:37 a.m., the COC indicated Resident 1 had increased confusion, hit his right leg on the bed frame and was bleeding from a skin tear on his right lower leg. During a review Resident 1's COC dated 3/5/2025 and timed at 6:01 a.m., the COC Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055041 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Beach Post-Acute 2725 Pacific Avenue Long Beach, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 1 was tired, more confused and drowsier after an incident of a bleeding from his right leg skin tear and swelling on his right lower leg. During a review of Resident 1's Fall Incident Report dated 3/5/2025 and timed at 11:27 a.m., the Fall Incident Report indicated Resident 1 had an unwitnessed fall and was found on the floor near his bathroom with more confusion. (GI bleeding can lead to confusion, fatigue, tiredness, weakness, dizziness, and falls). During a review of Resident 1's COC dated 3/6/2025 and timed at 2:09 p.m., the COC indicated Resident 1 had a small amount of black tarry stool (occurs when there is bleeding in the upper digestive system, black or brown in color, with a sticky consistency and may have an unpleasant odor), Resident 1's physician ordered a STAT CBC. During a review of Resident 1's Lab Results Report dated 3/6/2025 and timed at 8:05 p.m., the Lab Results Report indicated Resident 1's hemoglobin result was 7.0 grams per deciliter ([g/dl] a unit of measurement; reference range is 13.5 g/dl to 16.9 g/dl). Review of Resident 1's Lab Results Report for the previous day, 3/5/2025 and timed at 12:09 AM, documented Resident 1's hemoglobin was 8.5 g/dl, a significant decrease. During a review of Resident 1's Nursing Progress Notes dated 3/6/2025 and timed at 11:31 p.m., the Nursing Progress Notes indicated Resident 1's physician was notified of Resident 1's hemoglobin result, pending a response (order). During a review of Resident 1's Nursing Progress Notes dated 3/7/2025 and timed at 8:12 a.m., the Nursing Progress Notes indicated Resident 1 was hypotensive (low blood pressure [BP]) with a BP of 86/48 millimeters of mercury (mm/Hg). (reference range 120/80 mm/Hg). The Nursing Progress Notes indicated the paramedics were called but Resident 1's Responsible Party (RP) refused to transfer Resident 1 to a GACH due to a paracentesis (a medical procedure that removes fluid from the abdominal cavity) appointment that was scheduled for that day (3/7/2025). The Nursing Progress Notes indicated Resident 1's physician was aware and ordered a STAT CBC to be completed when Resident 1 returned from his appointment. Review of Resident 1's previous BP and Heart Rate (HR) measurements documented: 3/4/25 at 3:51 PM with BP of 130/84 and HR of 80, 3/5/25 at 5:44 AM with BP of 128/68 and HR of 68 at 9:40 PM with BP of 114/67 and HR of 80, 3/6/25 at 1:38 with BO of 114/67 and HR of 80, at 2:15 PM with BP of 121/62 and HR of 77. During a review of Resident 1's Order Summary Report (Physician's Order) dated 3/24/2025, the Physician's Order indicated a STAT CBC was ordered on 3/7/2025 at 8:28 a.m. and reordered at 2:20 p.m. upon Resident 1's return to the facility from paracentesis appointment. During a review of Resident 1's Nursing Progress Notes dated 3/7/2025 and timed at 2:20 p.m., the Nursing Progress Notes indicated Resident 1 returned to the facility after his paracentesis appointment and the lab was called to confirm Resident 1's lab order for a STAT CBC.During a review of the Laboratory Call Log Recording on 3/7/2025 at 2:20 p.m., the Laboratory Call Log Recording indicated Licensed Vocational Nurse (LVN) 1 spoke to laboratory personnel indicating she was following up on an order for a CBC for Resident 1. The Laboratory Call Log Recording did not indicate that LVN 1 said the lab order was STAT. During a review of the laboratory's Dispatch Log dated 3/7/2025, the Dispatch Log indicated a phlebotomist (a healthcare professional trained to collect blood samples from patients) attempted to draw Resident 1's blood on 3/7/2025 at 10:09 p.m. (approximately eight hours after the order was placed on 3/7/2025 at 2:20 p.m.) but Resident 1 refused. A review of Resident 1's untimed Nursing Progress Note dated 3/7/2025, the Nursing Progress Note indicated there was no documentation that Resident 1's physician or RP were notified when Resident 1 refused to have his blood drawn. During a review of Resident 1's Physician's order dated 3/7/2025, and timed at 11:59 p.m., the Physician's Order indicated a STAT CBC for Resident 1. During a review of Resident 1's Lab Results Report dated 3/8/2025, the Lab Results Report indicated Resident 1's labs were drawn on 3/8/2025, at 9:44 a.m., (almost 10 hours after the order was made on 3/7/2025 at 11:59 p.m.). The Lab Results Report indicated Resident 1's hemoglobin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055041 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Beach Post-Acute 2725 Pacific Avenue Long Beach, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few result was critical at 6.7 g/dl, his hematocrit count was 21.5%, (reference range is 39.5% to 50.0%) and his platelet count was 52,000 platelets per microliter ([mcl] with a reference range of 150, 000 to 400,000 platelets per mcl). The Lab Results Report indicated Resident 1's lab results were available at 11 a.m., on 3/8/2025, and the lab attempted several times to notify the facility of Resident 1's critical lab value but was unable to reach the facility until 3/8/2025 at 1:31 p.m., because no one at the facility picked up the phone. Review of The National Cancer Institute (NCI) grading of anemia documented Mild anemia is defined as Hemoglobin levels between 10.0 g/dL and the lower limit of normal. Moderate anemia is defined as Hemoglobin levels between 8.0 and 10.0 g/dL. Severe anemia is defined as Hemoglobin levels below 8.0 g/dL, and Life-threatening anemia is defined as Hemoglobin levels below 6.5 g/dL. During a review of the Laboratory Call Log dated 3/8/2025, the Laboratory Call Log indicated lab personnel attempted to report Resident 1's critical hemoglobin result to the facility at 11 a.m., 11:54 a.m., 12:19 p.m., 12:53 p.m., and 1:14 p.m. The Laboratory Call Log indicated Resident 1's critical laboratory result (hemoglobin) was finally reported to the facility on 3/8/2025 at 1:31 p.m. (more than 12 hours after the order was made on 3/7/2025 at 11:59 p.m.). During a review of Resident 1's Transfer Form dated 3/8/2025 and timed at 2:17 p.m., the Transfer Form indicated Resident 1 was transferred to a GACH at 3:30 p.m., due to black tarry stools, a decreased hemoglobin, a low hematocrit and a low platelet count. During a review of the GACH's Emergency Department (ED) Note dated 3/8/2025 and timed at 4:10 p.m., the ED Note indicated Resident 1 was admitted to the ED with a chief complaint of three episodes of black tarry stools within two days, a hemoglobin of 6.7 g/dl, and a chronic (last for an extended period, typically, for three months or more) hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to Resident 1's lower extremities (legs). The ED Note indicated Resident 1 received 1 unit of packed red blood cells ([PRBC] a concentrated preparation of red blood cells [specialized cells that circulate in the blood steam] obtained from whole blood after the plasma {the liquid component of whole blood}is removed) and was admitted to the GACH's telemetry unit (a specialized ward where patients requiring continuous cardiac monitoring receive care) because his condition was unstable. During an interview on 3/20/2025 at 1:20 p.m., Registered Nurse Supervisor (RNS) 1 stated a STAT lab order should be completed within four hours, and the lab result should be reported to the facility within two hours. During a subsequent interview on the same day at 2:05 p.m., RNS 1 stated Resident 1 had an order for a STAT CBC on 3/7/2025 at 8:28 a.m., but Resident 1's blood was not drawn until 3/8/2024 at 9:44 a.m. RNS 1 stated there was miscommunication between the licensed nursing staff on 3/7/2024 on all shifts which delayed Resident 1's STAT lab order. RNS 1 stated there was no follow up on Resident 1's lab order to ensure his labs were completed and results obtained. During an interview on 3/20/2025 at 3:31 p.m., RNS 2 stated she worked on the 3 p.m., to 11 p.m., shift on 3/7/2025 and received a report from RNS 1, who worked the 7 a.m., to 3 p.m. shift (3/7/2025), that Resident 1 had an order for a STAT CBC. RNS 2 stated she processed the lab order but when the lab technician came to the facility (3/8/2025) Resident 1 refused to have his blood drawn. During a subsequent interview on 3/24/2025 at 6:24 p.m., RNS 2 stated she reordered another STAT CBC for Resident 1 on 3/7/2025 11:59 p.m. and verbally endorsed the order to the 11 p.m. to 7 a.m. shift and documented the endorsement in the facility's communication board through their electronic medical record system. RNS 2 stated she did not call Resident 1's physician to notify him that Resident 1 refused to have his blood drawn. RNS 2 stated she should have called the physician and Resident 1's RP to notify them of Resident 1's refusal and to allow Resident 1's physician to give instructions for Resident 1's care. During an interview on 3/20/2025 at 3:50 p.m., RNS 3, who worked from 7 a.m. to 3 p.m., on 3/8/2025, stated he did receive an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055041 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Beach Post-Acute 2725 Pacific Avenue Long Beach, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete endorsement from the 11 p.m., to 7 a.m. shift regarding a STAT CBC for Resident 1. RNS 3 stated he checked the facility's Electronic Communication Board after conducting resident rounds and saw an order for a STAT lab for Resident 1. RNS 3 stated the STAT lab order had not been completed and there was no documentation in Resident 1's Progress Notes, why it had not been done. During an interview on 3/25/2025 at 5 p.m., after listening to the Laboratory Audio Call Log, LVN 1 stated she did not tell the lab that Resident 1's lab order was STAT. LVN 1 stated she should have communicated with the lab that Resident 1's lab order was STAT to ensure the labs were done based on the doctor's order and to prevent a delay in obtaining the blood sample and results. During a telephone interview on 3/25/2025 at 1:24 p.m., Resident 1's Physician stated Resident 1 had a GI bleed and had he been notified of Resident 1's refusal to have his blood drawn, he could have reordered another lab or sent Resident 1 to the GACH to be evaluated, instead of waiting. During an interview on 3/25/2025 at 2 p.m., the ADM acknowledged and stated there was a gap of time between Resident 1's lab order and results of his labs caused by the licensed nursing staff. During an interview on 3/26/2025 at 5:13 p.m., the DON stated there was a lack of communication amongst the licensed nurses and because of that they did not ensure Resident 1's lab was completed, and results obtained. The DON stated staff should have notified Resident 1's physician as well as Resident 1's RP when Resident 1 refused to have his blood drawn to prevent a delay in the care of Resident 1. During a review of the facility's P/P titled Processing Physician Orders dated 8/2017, the P/P indicated the facility shall maintain accuracy of physician orders to provide appropriate care and services related to patients/residents' risks. During a review of the facility's undated P/P titled Reporting Laboratory Test Results the P/P indicated the facility shall ensure all emergency laboratory draws should have results in two to six hours but did not specify the timeliness standards for physician order and blood collection. During a review of the facility's Laboratory Services Agreement, dated 7/22/2019, the agreement did not outline the time expectations for emergency laboratory orders; including both laboratory drawings and results. Please also see F580. Event ID: Facility ID: 055041 If continuation sheet Page 7 of 7