Health inspection·April 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to secure the personal belongings for one of six sampled residents (Resident 39) by misplacing Resident 39's phone charger, wheelchair, and clothes. This failure had the potential to negatively affect the Resident 39's psychosocial well-being. Findings: During a review of Resident 39's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included irritable bowel syndrome ( common condition that affects the digestive system causing abdominal pain, bloating, and changes in bowel habits including diarrhea or constipation or both), hematemesis (vomiting of blood)sepsis (a life-threatening blood infection),and muscle weakness. During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 3/30/2025, the MDS indicated the resident's cognition (thought process) is intact and required substantial/ maximal assistance (helper does more than half the effort) with transfer to and from a bed to a chair(or wheelchair), bed mobility, lower body dressing, toileting hygiene and personal hygiene. During a review of Resident 39's Resident's Clothing and Possessions (inventory of resident's belongings and property)dated 3/27/2025, Resident's Clothing and Possessions indicated the resident did not have any belongings on admission. The Resident's Clothing and Possessions indicated it was not signed by the resident or responsible party but signed by a facility's staff. During a review of facility's Theft and Loss Log( a record documenting instances where resident's personal property is lost or stolen) dated January 2025 to March 2025,the facility's Theft and Loss Log indicated Resident 39's phone charger , wheelchair and clothing were not listed. During an interview on 4/8/2025, at 11:18 a.m. with Resident 39, Resident 39 stated his wheelchair, phone charger, walker and some of his clothes were missing. Resident 39 stated he had spoken to the social services about his missing belongings. During an interview and record review of Resident 39's Clothing and Possessions on 4/11/2025, at 9:25 a.m. with Certified Nursing Assistant (CNA 1), CNA1 stated CNA's are responsible in updating or documenting any clothes or belongings in the clothing and possession list on admission and readmission. CNA 1 stated the resident complained about missing socks and clothes. CNA1went to Resident 39's room and told CNA 1 that the belongings located in his closet such as sweatshirts, jackets, shirts, Page 1 of 31 055123 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pants, cell phone, phone charger belonged to him. CNA1 stated resident's Clothing and Possession List should have been updated. During a concurrent interview and record review on 4/11/2025,at 10:05 a.m. with Licensed Vocational Nurse (LVN3), LVN 3 stated CNAs and Licensed Nurses are responsible in updating the resident's clothing and possessions list. LVN3 stated he remembered the resident had a wheelchair and was sent out to a hospital. LVN 3 stated the staff should have checked his belongings to ensure nothing was missing. During an interview on 4/11/2025, at 11:50 a.m. with Social Service Director (SSD), SSD stated if a resident's clothes or belongings are missing, the facility document the missing items in the Theft and Loss Log and then they will investigate. SSD stated the resident was sent out to a hospital and was readmitted to the facility. SSD stated the resident had personal belongings because he was in the facility for a while. SSD stated she was not aware the resident had missing clothes and wheelchair. SSD stated the resident had a missing phone charger and was not recorded in the facility's Theft and Loss Log because the facility had an extra phone charger and had replaced the resident's phone charger. SSD stated the resident would feel like the facility was not doing anything about his missing personal belongings and his clothing and possession list should have been updated by the staff to ensure nothing was missing. SSD stated the missing personal items should have been investigated by the facility. During an interview on 4/11/2025, at 2:48 p.m. with Director of Nursing (DON), DON stated the CNA's would list the resident's possessions when they get admitted in Clothing and Possessions List and the list will be updated when new belongings were brought in by the resident or family representative. DON stated not addressing resident's missing belongings could violate his right to keep and retain his personal belongings in the facility. During a review of facility's facility and procedure (P&P) titled Theft and Loss Program, revised 1/2017, the P&P indicated an inventory will be made of all resident's property brought into the facility and the resident or family representative will sign the form upon completion. The P&P indicated an immediate investigation should be completed by the Social Services and a Theft and Loss Log will be used by Social Services to document all occurrences of theft and loss in the facility whenever a loss occurs. During a review of facility's P&P titled Resident Rights, revised 9/2017, the P&P indicated the facility will protect and promote the rights of each resident including the right to retain and use personal possessions , to the maximum extent that safety and space permits. 055123 Page 2 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure a preadmission screening and annual review of a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for two of four reviewed residents (Residents 38 and 57). Residents Affected - Few This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident 38 and 57. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility 12/18/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 4/2/2025, the MDS indicated Resident 38's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 38 required maximum assistance (helper does more than half the work) with eating, oral hygiene, and personal hygiene. During a concurrent interview and record review on 4/10/2025 at 4:39 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 38 has diagnoses of schizophrenia and bipolar disorder and had a negative PASARR screening. MDSN stated it should have been positive. MDSN stated the PASARR was an assessment for those with mental illness to provide them with the appropriate and special services offered so it was important that it was done accurately. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder like depression {mood disorder that causes persistent feelings of sadness and loss of interest} and mania {mental state of an extreme high or depressive lows} and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 cognition was intact and required maximum assistance for activities of daily living ({ADLs}- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent interview and record review on 4/10/2025 at 4:39 a.m., with MDSN, the MDSN indicated Resident 57's PASARR indicated a positive PASARR Level I, but no PASARR Level II was completed because Resident 57 was unable to participate in the evaluation. MDSN stated she should have done another PASARR Level I for Resident 57 because he was alert and oriented and capable of making decisions. During an interview on 4/11/2025 at 2:47 p.m., with the Director of Nursing (DON), the DON stated it was the responsibility of the facility to ensure accurate completion of the PASARR, so the residents receive the necessary care they need. The DON stated if a resident has a positive PASARR, they 055123 Page 3 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0645 should receive a PASARR Level II screening to ensure their needs were met. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, PASARR (Preadmission Screening Resident Review), dated 3/2019, the P&P indicated, It is the policy of the facility to screen each resident for mental illness and intellectual disability. Residents Affected - Few 055123 Page 4 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to prevent or reduce the risk of contracture (loss of motion of a joint associated with stiffness and joint deformity) development for two of seven sampled residents (Residents 14 and 33) who were identified as having range of motion (ROM, full movement potential of a joint) limitations and were at high risk for contracture development. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 14 and 33. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Annual Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including left hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) and gout (form of arthritis that occurs when uric acid builds up in the blood and causes joint inflammation). 055123 Page 5 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 had severely impaired cognition. The MDS indicated Resident 33 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 33 had functional limitations in ROM in both arms and one leg. During a concurrent observation and interview on 4/8/2025 at 9:54 am, Resident 33 was lying in bed with both legs elevated on pillows with the right ankle crossed over the left ankle. Resident 33 stated he used to receive therapy services at the facility but no longer received them and was unsure why. Resident 33 was unable to make a full fist with the left hand, bent the left elbow minimally, and was unable to move the left shoulder. During a concurrent interview and record review on 4/10/2025 at 5:06 pm, the Minimum Data Set Coordinator (MDSC) stated a comprehensive (inclusive, including everything necessary) and individualized care plan was developed for every resident and used as a guide to ensure proper care was provided for each resident. The MDSC reviewed Resident 14's MDS, dated [DATE], and JMA, dated 12/11/2024, and confirmed Resident 14 was identified as having ROM limitations in both legs. The MDSC reviewed Resident 33's MDS, dated [DATE], and confirmed Resident 33 was identified as having ROM limitations in both arms and one leg. The MDSC stated Resident 14 and Resident 33 were at high risk for contracture development since they had existing ROM limitations and had no services in place such as therapy and/or a Restorative Nursing Aide Program (RNA, nursing aide program that helps residents maintain their function and joint mobility). The MDSC reviewed Resident 14 and Resident 33's care plans and confirmed there were no care plans and interventions in place to address Resident 14 and Resident 33's ROM limitations and high risk for contracture development. The MDSC stated the facility had a care plan titled, Risk for Contractures and Resident 14 and Resident 33 should have had that specific care plan but did not. The MDSC stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. The MDSC and Minimum Data Set Assistant (MDSA) stated residents may not receive the treatment and services they required if the appropriate care plans were not developed to address each area of concern. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated comprehensive care plans were developed for every resident and were used as a guide and communication tool for staff to identify the type of care to provide the residents in the facility. The DON stated a care plan with goals and interventions should be developed for all residents who were identified as having ROM limitations upon assessment, screens, and/or by report from the resident or staff. The DON stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, revised 3/2019, the P&P indicated a comprehensive, resident-centered care plan would be developed for each resident that included measurable objectives and timeframes to meet each resident medical, nursing, and mental and psychosocial needs. The P&P indicated the care plan must include the services that were to be furnished to assist the resident attain or maintain that level of physical, mental, and psychosocial well-being that the resident desired or that was possible. 055123 Page 6 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

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** b. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marker by tremor, muscular rigidity, and slow, imprecise movement) and dementia (a progressive state of decline in mental abilities). Residents Affected - Some During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severe cognitive impairment and was dependent (helper does all the effort) with ADL's. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder like depression {mood disorder that causes persistent feelings of sadness and loss of interest} and mania {mental state of an extreme high or depressive lows} and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 cognition was intact and required maximum assistance for Activities of Daily Living ({ADLs}- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent interview and record review on 4/11/2025 at 10:48 a.m., with LVN 3, LVN 3 confirmed there was no COC completed for Resident 56's new lump (areas of abnormally raise skin) on his arm nor was there a COC completed for Resident 57's fall, urinary tract infection (infection of any part of the urinary system), or gastrostomy tube (GT a feeding tube surgically placed through the abdominal wall directly into the stomach) dislodgement (being removed). LVN 3 stated a COC was crucial and should have been done for Resident 56 and Resident 57 to ensure they are aware of what was going on with the resident and to prevent these incidents from occurring again. During an interview on 4/11/2025 at 2:47 a.m., with the DON, the DON stated COC's are important to do because it was used as a communication tool between the nurses. The DON stated if a COC was not completed the staff will be unaware of what was occurring with the resident and the resident may then not receive the proper care and services required. During a review of the facility's policy and procedure (P&P), titled, Change of ConditionSBAR-Assessment, dated 5/2016, the P&P indicated, If there is a significant change in a resident's physical or mental condition, a thorough assessment of the resident's condition must be done by a licensed nurse. Based on interview and record review, the facility failed to ensure three out of six sampled residents ( Resident 39, Resident 56 and Resident 57) were provided necessary care and services when: a. Resident 39 was not provided medications for constipation (a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) when Resident 39 had no bowel movement (BM- movement of feces through the bowel and out the anus) for four days. b. Facility failed to initiate change in condition (a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) assessment for 055123 Page 7 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0684 Resident 56 and Resident 57. Level of Harm - Minimal harm or potential for actual harm These failures had the potential to cause delay in provision of necessary care and treatment to Resident 39, Resident 56, and Resident 57. Residents Affected - Some Findings: a. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including irritable bowel syndrome ( common condition that affects the digestive system causing abdominal pain, bloating, and changes in bowel habits including diarrhea [loose stool] or constipation or both), hematemesis (vomiting of blood)sepsis (a life-threatening blood infection),and muscle weakness. During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 3/30/2025, the MDS indicated Resident 39 had intact cognition (ability to think, understand, learn, and remember). Resident 39 required substantial/ maximal assistance (helper does more than half the effort) with transfer to and from a bed to a chair (or wheelchair), bed mobility, lower body dressing, toileting hygiene and personal hygiene. During a review of Resident 39's Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily) Task Screen, the ADL Task Screen for bowel elimination indicated Resident 39 had not had a bowel movement from 4/7/2025 to 4/10/2025 (four days). During a review of Resident 39's Care Plan titled Constipation/ Impaction initiated 3/27/2025, the Care Plan goals indicated the resident will have a bowel movement at least every three days and will be free from fecal impaction (hardened stool that's stuck in the rectum or lower colon). The Care Plan interventions included monitoring of bowel movement every shift, observing closely for any signs and symptoms of fecal impaction and administration of milk of magnesia (MOM- medicine that treats constipation), Dulcolax suppository (medicine used to treat constipation) if MOM is not effective for constipation. During a review of Resident 39's Physician Order Summary Report dated 3/27/2025, the Physician Order Summary Report indicated a physician order of MOM 30 milliliter (ml- unit of measurement) by mouth as needed for bowel management daily as needed if no BM for 3 days and bisacodyl (Dulcolax) suppository 10 milligrams (mgs.- unit of measurement) per rectum( through the rectum) as needed for constipation once daily if MOM is ineffective after 8 hours of administration. During a review of Resident 39's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/1/2025 to 4/11/2025, the MAR indicated the resident did not receive MOM, or Dulcolax suppository as ordered by the physician to be given for no BM for three days. During an interview on 4/11/2025, at 11:00 a.m. with Certified Nursing Assistant (CNA1), CNA 1 stated she did not know how to check in the resident's electronic chart if the resident had no bowel movement for days but would report to the charge nurse if the resident had experienced stomach pain or passage of hard stool. CNA 1stated it was important to report any irregularities in residents' bowel movement because it could lead to hospitalization. During a concurrent interview and record review on 4/11/2025, at 10:36 a.m. with Licensed 055123 Page 8 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0684 Level of Harm - Minimal harm or potential for actual harm Vocational Nurse (LVN 3), reviewed Resident 39's ADL Task Screen for Bowel Elimination. LVN 3 confirmed Resident 39 had no BM on 4/7/2025, 4/8/2025, 4/9/2025, and 4/10/2025. LVN 3 stated the licensed nurses should have called the physician to obtain order or administer the MOM for constipation. LVN 3 stated the certified nursing assistants usually would notify him if the resident had no BM for three days so he could determine if the resident could be given medicine to treat the constipation or notify the physician. Residents Affected - Some During a concurrent interview and record review on 4/11/2025 at 11:18 a.m. with Director of Staff Development (DSD), reviewed Resident 39's ADL Task Screen for Bowel Elimination at 11:18 a.m. the DSD stated the certified nursing assistants should notify the charge nurse if a resident had no BM for three days and should look back on Resident 39's health record on how long the resident had no bm. DSD stated the CNA should have reported resident's having no bowel movement for three days to the charge nurse because constipation could lead to fecal impaction and could increase the risk of hospitalization. During an interview on 4/11/2025, at 2:48 p.m. with the Director of Nursing (DON), the DON stated the CNAs should have notified the charge nurse when Resident 39 had no BM for three days because constipation could lead to bowel obstruction (partial or complete blockage of small or large intestines which is life threatening). During a review of facility's Job Description of a Charge Nurse, the Job Description of a Charge Nurse indicated the licensed nurse will perform treatments, administer medications, and implement other nursing interventions as indicated by the resident care plan or as ordered by the physician. During a review of facility's Job Description of Certified Nursing Assistant, the Job Description of CNA indicated the certified nursing assistant will check and report bowel movements, stool condition and report significant changes in the resident's condition to a LVN or RN as soon as practical. 055123 Page 9 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments and services to one of seven sampled residents (Resident 14) to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) by failing to: 1.Ensure Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, included the assessment of Resident 14's left knee ROM. 2.Ensure Resident 14's Quarterly JMA, dated 6/2024, was completed. These deficient practices had the potential to result in missed opportunities for identifications of ROM declines and cause Resident 14 to have a decline in overall physical functioning and ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Annual JMA dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and 055123 Page 10 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had a left AKA and ROM limitations in both shoulders and the right leg. During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes. During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the left ankle minimally. During an interview on 4/8/2025 at 2:58 pm, the Director of Rehabilitation (DOR) stated the facility monitored for changes in a resident's joint ROM by JMAs performed by the Rehabilitation Department (Rehab) and nursing along with notification from nursing staff of any observable changes. The DOR stated Rehab performed a detailed JMA which included a ROM assessment of each resident's arms and both legs upon admission, annually, and upon a change of condition. The DOR stated nursing monitored for changes in a resident's ROM through the completion of the MDS and quarterly JMAs. The DOR stated it was important JMAs were completed accurately and timely to ensure staff identified any declines in a resident's ROM and proper treatments and services were provided to the residents. During a concurrent interview and record review on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA stated they compared a resident's ROM of each joint to the previous JMA and performed their own physical assessment of the resident's joints to check for any ROM changes. The MDSC and MDSA reviewed Resident 14's JMAs and clinical record. The MDSC and MDSA confirmed the quarterly JMA for 6/2024 was not done. The MDSC stated a quarterly JMA should have been done in 6/2024 since JMAs were supposed to be done quarterly along with the MDS but was not and was unsure why. The MDSC and MDSA confirmed the JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, did not include an assessment of Resident 14's left knee. The MDSC and MDSA confirmed Resident 14 had a left BKA, not a left AKA as was incorrectly documented on the JMAs. The MDSC and MDSA stated Resident 19's left knee ROM should have been assessed but was not and was unsure why it was overlooked for multiple JMAs. The MDSC stated it may have been mistakenly overlooked since the diagrams of the left knee and left ankle assessments were crossed out and incorrectly indicated Resident 14 had a left AKA. The MDSC stated missed JMAs, and lack of ROM assessment of every joint could potentially result in missed opportunities to identify ROM declines, ROM decline, and contracture development. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The DON stated it was important JMAs assessed the ROM of all resident's joints and were done routinely and timely as required to ensure the facility promptly identified any ROM changes and provided the appropriate services to address any declines and prevent contractures. 055123 Page 11 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's Policy and Procedure (P&P) titled, Limitations in ROM and Mobility and Referrals for Therapy, revised 10/2017, the P&P indicated a resident with limited ROM would be assessed and provided appropriate treatment and services to increase ROM and/or prevent a further decrease in ROM. The P&P indicated the appropriate therapy department would screen residents upon admission and quarterly. The P&P indicated a resident's comprehensive assessment should include and measure a resident's current extent of movement and the identification of any limitations and opportunity for improvement. CROSS REFERENCE TO F726 amd F842. 055123 Page 12 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) were competent in providing quarterly Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) affecting one of seven sampled residents (Resident 14) with limited range of motion (ROM, full movement potential of a joint). This deficient practice resulted in multiple missed assessments of Resident 14's left knee, failure to identify inaccurate documentation and assessment of Resident 14's left leg, missed opportunities to identify and report ROM decline, and had the potential to lead to ROM decline and contracture (loss of motion of a joint associated with stiffness and joint deformity) development. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes. During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in 055123 Page 13 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally. During an interview on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA stated they never received competencies or formal instruction on how to administer JMAs. During a review of the employee files for the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA), the employee files did not include a performance competency for ROM or for performing the JMA. During an interview on 4/11/2025 at 8:50 am, the Director of Rehabilitation (DOR) stated changes in joint ROM were monitored by JMAs performed by the Rehabilitation Department (Rehab) and nursing along with notification from nursing staff of any observable changes. The DOR stated Rehab performed a detailed JMA which included a ROM assessment of each resident's arms and both legs upon admission, annually, and upon a change of condition. The DOR stated nursing monitored for changes in a resident's ROM through the completion of the quarterly JMAs and MDS. The DOR stated it was important staff were competent to perform JMAs to ensure the assessments were accurate and any changes or declines in ROM could be identified and reported. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated the MDSC and MDSA were responsible for conducting the quarterly JMAs for the residents in the facility to monitor for changes in joint ROM. The DON stated there were no competencies and/or formal training given to the MDSC and MDSA on how to conduct the quarterly JMAs. The DON stated ROM was a part of nursing skills, but the MDSC and MDSA did not perform ROM daily as a part of nursing practice as their job duties did not require them to do so. The DON stated nursing generally assessed ROM differently from Rehab since nursing looked at ROM in terms of general activities of daily living (ADL, basic activities such as eating, dressing, toileting) function and Rehab assessed every joint individually and in detail. The DON stated the MDSC and MDSA should have had competencies and formal instruction on how to accurately perform JMAs but did not. The DON stated it was important staff were competent to ensure assessments were accurate and any declines in ROM were appropriately identified and reported. During a review of the facility's Policy and Procedure (P&P) titled, Staff Competencies, revised 1/2017, the P&P indicated each employee would receive periodic performance reviews to ensure staff competencies. The P&P indicated performance evaluations were to ensure staff had the appropriate competencies and skills to assure resident safety and to provide care which included assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. The P&P indicated all performance evaluations of staff would be completed during their orientation and annually. CROSS REFERENCE TO F688 and F842 055123 Page 14 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and address one of four sampled residents (Resident 53) behavioral health needs by failing: A. to ensure Brief Trauma Screening Questionnaire (tool used to assess an individual's potential exposure to traumatic events and their current PTSD symptoms and this tool is used to help identify individuals who may need further assessment or support for trauma) for Resident 53 who had a diagnosis of Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) was assessed and screened properly by social service personnel. This failure had the potential for Resident 53 for not receiving appropriate care to meet his behavioral needs. Findings: During a review of Resident 53's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included PTSD, dementia( progressive state of decline in mental abilities), personal history of military service (a collection of information which permanently documents a service members career in the in the army, air forces and naval forces). During a review of Resident 53's Minimum Data Set (MDS- a resident assessment tool) dated 2/15/2025, the MDS indicated the resident had severely impaired cognitive skills ( a significant decline in intellectual capacity and characterized by difficulties in memory, thinking, learning, and judgement affecting daily life activities) and required substantial/ maximal assistance (helper does more than half) with toileting hygiene, bathing, dressing and personal hygiene. The MDS indicated the resident had a diagnosis of PTSD. During a review of Resident 53's Brief Trauma Questionnaire and Life Events Checklist( tool used to assess an individual's history and experiences and these questionnaires can help identify individuals who may benefit from further assessment and treatment for trauma-related disorders like PTSD) dated 2/2/2025,the Brief Trauma Questionnaire and Life Events Checklist indicated the resident did not experience combat or exposure to a warzone in the military or as a civilian and had no history of traumatic events. During a review of Resident 53's Psychosocial Assessment Form (tool used to collect comprehensive information about an individual's psychosocial, social and environmental factors to help understand resident needs )dated 2/4/2025, the Psychosocial Assessment Form indicated had a history of military service for two years. During an interview on 4/11/2025, at 9:57 a.m. with Certified Nursing Assistant (CNA1), CNA 1 stated Resident 53 would yell suddenly because of pain. CNA1 stated she was not aware the resident had PTSD. 055123 Page 15 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/10/2025, at 1:38 p.m. with Licensed Vocational Nurse (LVN 4), LVN 4 stated the resident did not show any behavioral symptoms for PTSD and was not aware what could trigger resident's PTSD. During a concurrent interview and record review of Resident 53's Brief Trauma Questionnaire and IDT Care Conference Summary dated 2/4/2025 with Director of Social Service (DSS), DSS confirmed the resident had PTSD as one of the diagnoses but did not know what could trigger resident's behavior for PTSD. DSS stated the Brief Trauma Questionnaire did not indicate resident's history of military service or exposure to war. DSS stated Resident 53's Brief Trauma Questionnaire and Life Event Checklist did not identify resident's exposure to traumatic events like war because resident was not properly screened and assessed. DSS stated Resident 53 would not receive appropriate services that would address his PTSD, and the facility should be able to identify what could trigger Resident 53's PTSD so a plan of care could be created to manage his behavior. During an interview on 4/11/2025, at 2:48 p.m. with Director of Nursing(DON), DON stated it's important to properly screen and identify residents who had PTSD to ensure necessary services and care will be provided to the residents. DON stated knowing what could trigger the behavior will help with the management and development of plan of care. During a review of facility's policy and procedure (P&P) titled Trauma informed Care revised 1/2020, the P&P indicated the Social Service personnel will complete a Brief Trauma Questionnaire and Life Events Checklist that will serve as an assessment tool to determine if the resident had sustained a serious or traumatic life event. The P&P indicated the facility would have sufficient staff that would provide nursing and related services. The P &P indicated based on the comprehensive assessment will receive appropriate treatment and services to correct the assessed problem of a resident who displays or is diagnosed with a mental disorder or who has history of trauma and PTSD. 055123 Page 16 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to: Residents Affected - Some 1. Ensure open bag of frozen sausages was stored properly in the freezer. 2. Ensure freezer temperature was maintained at 0-degree Fahrenheit (F-unit of measurement) while frozen vegetables were stored. 3. Ensure gloves were used by kitchen staff when serving cooked food during tray line. 4. Ensure proper donning of glove and handwashing was observed when the [NAME] switched tasks from tray line to prepare food in the microwave. These failures had the potential to put residents at risk for food-borne illnesses ( any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and affect the quality of food. Findings: 1.During an initial kitchen observation and interview on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), an open bag of frozen sausages was inside an open box. Observed the frozen sausages had ice crystals on the surfaces.DM stated the open bag of frozen sausages should be stored in a sealed plastic bag. During an interview on 4/9/2025, at 1:30 p.m. with Registered Dietician (RD), RD stated open bag of frozen sausages not properly sealed can affect the quality of food. RD stated the kitchen staff should have transferred the frozen sausages in zip lock bag or tied the bag to preserve the moisture because the frozen food could dry out and can be exposed to bacteria. During a review of facility's policy and procedure (P&P) titled Procedure for Freezer Storage undated, the P&P indicated to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn (is a result of moisture loss from frozen food due improper packaging or storage). 2. During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees F and the reach in freezer for meat products was reading at 24 degrees F. DM stated the kitchen personnel just removed some food items from the freezers that's why the temperatures are not 0-degree F on both freezers. 055123 Page 17 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/8/2025, 2:15 p.m. with an unnamed technician (UT) in the kitchen, the UT stated that they were called to fix the freezers around noontime today because the temperatures were high. Observed the freezer's temperature was 10 degrees F for frozen vegetables and freezer for frozen meat products was at18 degrees F. During an observation on 4/9/2025, at 12:05 p.m. with DM, reach in freezer temperature for frozen vegetables was 10 degrees F. During a review of facility's recipe of stir-fry vegetables, the recipe indicated ingredients included assorted vegetables such as cauliflower, broccoli, squash, onions, zucchini and carrots and can use frozen or fresh. During an interview on 4/9/2025, at 12:10 p.m. and subsequent interview on 4/9/2025, at 1:17 p.m. with DM, DM stated he was aware the temperature of the freezer for the frozen vegetables was not maintained at 0-degree F or below since yesterday (4/8/2025). DM stated he was monitoring the temperature of the freezer and was waiting for the temperature to go down to 0 degree but did not happen yesterday. DM stated the Registered Dietician (RD),and the Administrator (ADM) were aware to reach in freezer for vegetables was not maintaining its proper temperature. DM stated they threw away some of the frozen food items at around 9:00 a.m. today but the kitchen used the vegetables from the non-working freezer for the stir fry vegetables that was served for lunch. DM stated residents could be at risk for unsafe food because of the vegetables used for the stir fry vegetables were not properly stored in the freezer. During a review of facility's Freezer Temperature Log for vegetables, the A.M. Temperature log of the freezer indicated a temperature of 10 degrees F on 4/9/2025. During an interview on 4/9/2025, at 12:51 p.m. with Dietary Aide (DA 1), DA 1 stated the DM told him to throw away the vegetables , and some breads from the freezer around 9:00 a.m. today and at that time the temperature of the freezer was 10 degrees F. DA 1 stated the vegetables used for the stir fry for lunch came from the freezer that was reading 10 degrees F. DA 1 stated the proper temperature to store frozen vegetables is 0 degree F to ensure freshness of food and to prevent bacterial growth that could place resident at risk for food borne illness. During an interview on 4/9/2025, at 12:50 p.m. with [NAME] (CK1), CK 1 stated the temperature of the freezer for the vegetables at around 4:00 a.m. was 10 degrees F. CK 1 stated that he pulled out broccoli, carrots, zucchini and cauliflower from the non-working freezer to prepare for the day's meal. CK 1 stated all the vegetables that was served for lunch was from the non-working freezer. CK 1 stated residents could get sick from consuming the food if the vegetables were not stored properly in the freezer. During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the temperature log of the freezer might not be reliable because it all indicated the temperatures are 0-degree F for several days and the situation could be going on for days. RD stated they should have discarded everything in the freezer because the facility does not know how long it had not been working. RD stated she was aware not all the food items stored in the non-working freezer was thrown away and was served for lunch today. During an interview on 4/9/2025, at 2:24 p.m. with Maintenance Supervisor, MS stated he was made aware yesterday by the DM about the non-working freezer. MS stated they started emptying the food 055123 Page 18 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some items in the freezer this morning and placed some of the food items in the other freezer. He said he would call the technician if the freezer needed repair. During a telephone interview on 4/9/2025, at 2:14 p.m. with Administrator (ADM), ADM stated when the freezer's temperature was over zero despite maintenance, the kitchen personnel should have discarded the food items stored in the freezer. ADM stated residents could get food poisoning from consuming the food that came from the freezer. 3. During a tray line observation on 4/8/2025, at 11:40 a.m. in the kitchen, cooked food items in trays were on the steam table as the [NAME] (CK1) took temperatures of each cooked food items then proceeded to start preparing a plate for each resident. Observed CK 1 and another kitchen staff were scooping cooked food items from the trays to a plate without wearing gloves as another kitchen personnel called out the diet of a resident. During an interview on 4/9/2025, at 12:10 p.m. with CK 1, CK 1 stated kitchen personnel do not wear gloves when handling and serving cooked food during tray line. During an interview on 4/9/2025, at 1:30 p.m. with RD, RD stated the kitchen staff should wear gloves when handling ready to serve and cooked food to prevent the risk of cross contamination (unintentional transfer of harmful bacteria from one surface or object to another). 4.During an observation on 4/9/2025, at 12:00 p.m. with CK 1, CK 1 wore a glove on the right hand without practicing hand washing first and brought a plate in the storage area to use the microwave. Observed CK 1 still wearing the glove on his right and continued serving in the lunch tray line without washing hands and removal of glove. During an interview on 4/9/2025, at 12:10 p.m. with CK 1, CK 1 stated hand washing should be practiced every time he touched another food item and admitted he committed in not practicing hand washing when he switched tasks. CK 1 stated he should have removed his glove and washed hands before serving food in the tray line to prevent cross contamination which could cause food-borne illnesses to the residents. During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the cook should have removed his glove and washed his hands in between tasks then put on new pair of gloves before returning to serve food in the tray line. RD stated handwashing should be performed because of the risk of cross contamination between different objects like the microwave. During an interview on 4/11/2025, at 2:48 p.m. with Director of Nursing (DON), DON stated not practicing handwashing in the kitchen could spread infection among the residents and staff. DON stated the facility had a policy to maintain and keep the temperature of the freezers zero or below zero to ensure the food that will be consumed by the residents are safe to eat. During a review of facility's P&P titled Food Handling undated, the P&P indicated the food will be prepared and served in a safe and sanitary manner. The P&P indicated Food and Nutrition Services personnel should never use bare hand contact with any foods , ready to eat or otherwise including food item preparation. During a review of Food Code 2022 U.S. Food and Drug Administration ( a model document published by U.S. Food and Drug Administration that provides guidance for regulating food safety in a retail 055123 Page 19 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0812 Level of Harm - Minimal harm or potential for actual harm setting such as restaurants, groceries and institutions like Nursing Homes), the Food Code 2022 U.S. FDA indicated food employees shall clean their hands immediately before engaging in FOOD preparation including before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands. Residents Affected - Some 055123 Page 20 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of seven sampled resident's (Residents 14 and 19) medical records were accurately documented when: a.Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, inaccurately indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee) instead of the correct diagnosis of a left below knee amputation (BKA, surgical removal of a limb below the level of the knee involving the removal of the foot and ankle joint). b.Resident 19's Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) physician's order inaccurately indicated for RNA to use a two-wheeled walker (mobility aid with wheels on the front two legs of the device) for walking exercises with Resident 19 instead of a platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) as recommended by Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function). These deficient practices had the potential to negatively impact the provision of necessary care and services, cause miscommunication among staff, cause a decline in function and safety concerns due to inappropriate use of assistive devices for mobility, and result in missed ROM assessments and opportunities to detect declines in joint range of motion (ROM, full movement potential of a joint). Findings: a.During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, 055123 Page 21 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Annual JMA dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had a left AKA and ROM limitations in both shoulders and the right leg. During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes. During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally. During a concurrent interview and record review on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA reviewed Resident 14's JMAs and clinical record. The MDSC and MDSA confirmed the JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, indicated Resident 14 had a left AKA and did not include assessments of Resident 14's left knee. The MDSC and MDSA confirmed Resident 14 had a left BKA, not a left AKA as was incorrectly documented on the JMAs. The MDSC and MDSA stated Resident 19's left knee ROM should have been assessed but was not and was unsure why it was overlooked for multiple JMAs. The MDSC stated it may have been mistakenly overlooked since the diagrams of the left knee and left ankle assessments were crossed out and incorrectly indicated Resident 14 had a left AKA. The MDSC stated inaccurate documentation could potentially result in missed opportunities to identify ROM declines, ROM decline, and inappropriate delivery of necessary care and services. During a concurrent observation, interview, and record review on 4/10/2025 at 2:24 pm, Physical Therapist 1 (PT 1) assessed Resident 14's left leg. PT 1 asked Resident 14 to bend the left knee. Resident 14 bent the left knee minimally. PT 1 reviewed Resident 14's JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, and confirmed the JMAs incorrectly indicated Resident 14 had a left AKA, instead of the correct diagnosis of a left BKA. PT 1 stated it was important JMAs were completed accurately as incorrect documentation could affect future assessments and services provided, lead to missed opportunities to identify declines, and result in ROM decline. b. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a right hemiplegia (weakness to one side of the body) and difficulty walking. 055123 Page 22 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was cognitively intact. The MDS indicated Resident 19 required substantial/maximal assistance with eating, partial/moderate assistance with walking, and was dependent for hygiene, bathing, toileting, dressing, and rolling to both sides. The MDS indicated Resident 19 had functional limitations in ROM in both arms. During a review of Resident 19's RNA/Certified Nursing Assistant (CNA) Referral Form, dated 3/25/2025, the RNA/CNA Referral Form indicated for RNA to assist Resident 19 with walking exercises using a platform walker, every day, five times a week. During a review of Resident 19's Physician Order Summary Report, the Physician Order Summary Report indicated a order, dated 3/25/2025, for RNA to assist Resident 19 with walking exercises using a two-wheeled walker, every day, five times a week. During an observation on 4/8/2025 at 11:04 am, observed Resident 19 was seated in a power wheelchair in the hallway. Resident 19's right hand was positioned in a fist and was unable to fully open the hand. The fingers of Resident 19's left hand was positioned with the thumb in hyperextension (the extension of a body part beyond it's normal limits) and the middle finger, ring finger, and small fingers bent into a fist. During an observation of Resident 19's RNA session on 4/10/2025 at 8:45 am, in the hallway, Resident 19 was seated in a power wheelchair with a platform walker positioned in front of him. Resident 19 leaned forward, grabbed the handlebars of the platform walker, put his upper body weight onto the platform walker with both forearms, and stood up with Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 2 (RNA 2)'s assistance. Resident 19 walked two laps around the facility with RNA 1 and RNA 2's assistance, sat down in power wheelchair, and remained seated in the hallway at the end of the session. During a concurrent interview and record review on 4/10/25 at 9:40 am, RNA 1 and RNA 2 reviewed Resident 19's RNA orders and RNA/CNA Referral Form. RNA 1 confirmed Resident 19's RNA orders and RNA/CNA Referral Form instructions did not match. RNA 1 stated PT instructed the RNAs to use a platform walker when performing walking exercises with Resident 19 during RNA training. RNA 1 and RNA 2 stated Resident 19 would be unable to grasp the handles of a two-wheeled walker because the ROM of both of his hands were very limited. RNA 1 and RNA 2 stated the RNA order was written incorrectly. During a concurrent interview and record review on 4/10/2025 at 10:01 am, the Director of Rehabilitation (DOR) stated a licensed therapist determined the type of exercises and assistive devices a resident used for RNA services and established an RNA program for the RNAs to carry out. The DOR stated the licensed therapist wrote the details of the RNA program on the RNA/CNA Referral Form and entered the RNA order into the electronic charting system. The DOR reviewed Resident 19's RNA order, dated 3/25/2025, and the RNA/CNA Referral Form, dated 3/25/2025, and confirmed Resident 19's RNA order was written incorrectly. The DOR stated the PT wrote for RNA to use a platform walker with Resident 19 for walking exercises on the RNA/CNA Referral Form and incorrectly wrote for RNA to use a two-wheeled walker for walking exercises on the RNA order. The DOR stated if documentation was inaccurate, it could lead to RNAs providing the incorrect type of service, using an incorrect or unsafe device, and could result in the resident not being able to safely perform the activity or exercises prescribed. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated it was important documentation was accurate to ensure the staff had a correct assessment of a resident's status and 055123 Page 23 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided the appropriate care and services. The DON stated if documentation was inaccurate, it could lead to inappropriate delivery of care and services, missed opportunities to identify declines or problem areas, safety concerns, and the development and implementation of an inaccurate care plan. During a review of the facility's Policy and Procedure (P&P) titled, Documentation Principles, revised 2/2018, the P&P indicated resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided for each resident. The P&P indicated entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive. CROSS REFERENCE TO F688 and F726 055123 Page 24 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification. This deficient practice resulted in the facility to have repeat deficiencies in comprehensive resident centered care plans, competent nursing staff, safe operating equipment, and the prevention of a decrease in range of motion (ROM- full movement potential of a joint). Findings: following repeat deficiencies in comprehensive resident centered care plans, competent nursing staff, safe operating equipment, and the prevention of a decrease in range of motion (ROM). During a concurrent interview and record review on 4/11/2025 at with the Director of Nursing (DON), the DON stated she will continue to work on and make further changes for the issues that were still areas of concerns. The DON stated they need to improve their care plan process, increase the frequency for monitoring of equipment, ensure the staff are responsible and being held accountable when checking the freezer temperatures, and increase staff education regarding ROM by providing in-services for the licensed nurses performing the ROM exercises. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance Improvement Committee (QAPI), dated 1/2017, the P&P indicated, The purpose of the QAPI committee is to provide a systematic self-evaluation process to identify and resolve problems. Input from regulatory agencies and consultants will be integrated in the QAPI committee review process (i.e. survey, complaint visits). The committee is responsible for overseeing the entire quality improvement program. It identifies and prioritizes issues for QAPI evaluation and aspects of care and monitors implementation of action plans recommended. 055123 Page 25 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to: Residents Affected - Some a.Change and label tube feeding water bag for Resident 28. b.Perform hand hygiene during wound care dressing change for Resident 56. c.Ensure Physical Therapist 1 (PT 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assessing Resident 14's left leg which required direct contact with Resident 14 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed reduce the transmission of multi-drug-resistant organisms). d. Licensed Vocational Nurse (LVN) 5 failed to sanitize blood pressure cuff in between residents. e. Ensure sanitary handling and transport of soiled linens. These deficient practice had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: a. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension ([HTN]- high blood pressure) and hemiplegia (weakness on one side of the body). During a review of Resident 28's Minimum Data Set ([MDS]- a resident assessment tool) dated 3/18/2025, the MDS indicated Resident 28 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 28 required maximal assistant with Activities of Daily Living ([ADL]- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview on 4/8/2025 at 10:42 a.m., with Licensed Vocational Nurse (LVN) 1 in Resident 28's room, LVN 1 stated Resident 28's tube feeding water bag was not labeled of date change and was unable to determine when it was changed. LVN 1 stated it was important to change and label the tube feeding water bags daily for infection control. During an interview on 4/11/2025 at 1:55 p.m., with the Infection Prevention Nurse (IPN), the IPN stated tube feeding water bags should be changed and labeled with date change daily to prevent the growth of bacteria which can cause the resident to develop stomach issues. During an interview on 4/11/2025 at 2:47 p.m., with the Director of Nursing (DON), the DON stated tube feeding water bags should be changed and labeled with changed date every 24 hours to prevent spoilage, stomach issues, and infection. b. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 055123 Page 26 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marker by tremor, muscular rigidity, and slow, imprecise movement) and dementia (a progressive state of decline in mental abilities). During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severe cognitive impairment and was dependent (helper does all the effort) with ADL's. During an observation on 4/10/2025 at 11:11 a.m., in Resident 56's room, LVN 1 was observed changing a wound dressing without performing hand hygiene after removing the soiled wound dressing and cleaning the site and before applying the clean wound dressing. During an interview on 4/10/2025 at 11:23 a.m., with LVN 1, LVN 1 stated he did not perform hand hygiene after handling the soiled dressing and before applying the clean dressing to Resident 56's wound. LVN 1 stated he should have performed hand hygiene for infection control and failure to perform hand hygiene had the potential for spread of infection. During a interview on 4/11/2025 at 2:01 p.m., with the IPN, the IPN stated hand hygiene should be performed in between removing the soiled dressing and applying the clean dressing when doing a wound care dressing change. LVN 1 stated hand hygiene was important to do to prevent infection and contamination of the wound which could potentially lead to an infection of the wound. During a continued interview on 4/11/2025 at 2:47 p.m., with the DON, the DON stated hand hygiene should be performed before, after removing the dirty dressing, and before applying the clean dressing to prevent contamination and infection. c. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a concurrent observation and interview on 4/10/2025 at 2:24 pm, with PT 1 in Resident 14's room, observed Resident 14 lying in bed. PT 1 entered Resident 14's room, put on gloves, and did not put on an isolation gown. PT 1 walked to Resident 14's bed, picked up Resident 14's left leg, asked Resident 14 to bend his left knee, and put Resident 14's leg back onto the bed. After completing assessment of Resident 14's left leg, PT 1 removed both gloves, exited the room, and used alcohol-based hand sanitizer. PT 1 stated he did not wear an isolation gown while providing direct care to Resident 14. PT 1 stated he should have worn an isolation gown while assessing Resident 14's left leg 055123 Page 27 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because he had direct contact with Resident 14 who was on EBP precautions. PT 1 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 4/10/2025 at 3:04 pm, the IPN stated the purpose of EBP was to minimize the risk of infection for residents with invasive devices (medical tools that enter the body either through a break in the skin or an opening in the body) such as foley catheters (thin, flexible rube inserted into the bladder to drain urine), gastronomy tubes (a tube placed directly into the stomach for long-term feeding), and open, non-healing wounds. The IPN stated all staff providing direct patient care for residents on EBP precautions must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated it was important all facility staff followed the proper infection control protocols to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Standard Precautions (ESP), revised 1/2024, the P&P indicated the purpose of ESP was to prevent Multi-Drug-Resistant Organisms (MRDO, bacteria resistant to many antibiotics) in skilled nursing facilities. The P&P indicated ESP was an approach of targeted gown and glove use during high contact resident care activities. The P&P indicated gowns and gloves were to be worn while performing high contact tasks associated with the greatest risk for MRDO contamination of hands, clothes, and the environment, which included any care activity where close contact with the resident was expected to occur. The P/P indicated, Change gloves, as necessary during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one). 5.During a concurrent observation and interview on 4/10/2025, at 9:03 a.m. with Maintenance Supervisor (MS), observed one plastic bag containing clean linen was torn and was on top of an uncovered laundry bin intended for clean linens and clothes located outside the facility. Observed two bags of dirty linens were on the floor next to the large blue bins and cart where the clean linens were located. MS stated the staff should not leave the soiled bags on the floor next to clean laundry bins and laundry cart to prevent spread of infection. MS stated they used an outside company to do the laundry of the residents, and the clean laundry was placed on the large blue laundry bins outside the facility. MS stated the staff would empty the soiled linens in the storage area outside the facility across the clean area where the bags of clean linens are located. During an interview on 4/10/2025, at 10:10 a.m. with CNA 2, CNA 2 stated the staff should not leave bags of soiled linens near the clean area where the blue clean laundry bins were located because of the risk of cross contamination and infection control. During an interview on 4/11/2025, at 11:39 a.m. with the Director of Staff Development (DSD), the DSD stated the laundry bins for the soiled linens were in the left side and on the right side was the blue laundry bins containing the clean bags of linens outside the facility. The DSD stated the laundry blue bins store the clean linens and should be covered to prevent cross contamination that could lead to spread of infection. The DSD stated the two bags of soiled linens should not be placed or laid on the floor next to the clean laundry bin because they were soiled and can cause spread of infection. The staff should have placed the bags of soiled linen directly to the laundry bins intended for soiled linens. 055123 Page 28 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/11/2025, at 1:56 p.m. with the IPN, the IPN stated failed to observed and practiced proper handling and transporting of soiled linens could make residents sick in the facility and had the potential to cause cross contamination. During an interview on 4/11/2025, at 2:48 p.m. with the DON, the DON stated that clean linens, and dirty linens should be separated when handling and transporting linens to prevent spread of infection among the residents and staff members. During a review of facility's policy and procedure (P&P) titled Infection Control-Laundry Services, revised 7/ 2019, the P&P indicated It is the responsibility of the facility to ensure all laundry was handled, stored, processed and transported in a safe and sanitary manner, regardless of where the laundry is processed. The P& P indicated Dirty linen should be clearly separated from areas where clean linen is handled, and workflow should prevent cross contamination. d. During an observation on 04/10/2025 at 4:57 p.m., during medication pass, observed LVN 5 brought a rolling blood pressure machine to resident room. LVN 5 failed to sanitize the BP cuff before and between resident use. During a concurrent observation and interview on 4/10/25 at 5:10 p.m , with LVN 5, LVN 5 stated she should sanitize the blood pressure cuff before and between resident use for infection control. During an interview on 4/11/2025 at 1:28 p.m., with the IPN, IPN stated the staff are required to disinfect equipment's such as the BP cuff before and after use to prevent cross contamination. During a review of the facility's policy and procedure (P&P) titled, Infection Control-DME dated 10/2011, the P&P indicated It is the policy of the facility to properly and routinely sanitize durable medical equipment (DME). When available, the manufacturer's instructions will be followed for cleaning non-critical care items. In the absence of manufacturer's cleaning instructions, the following will be used to clean and disinfect these items between resident use: 1.Bleach wipes or germicidal wipes will be used for DME after each use. 2.If any equipment has been potentially exposed to C-difficile (stool infection), a 1:10 bleach and water solution will be used to clean and sanitize. This solution should be allowed to remain on the item for 5 minutes. 3.It is the responsibility of the nursing personnel to properly and routinely sanitize DME after each use. 055123 Page 29 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure reach in freezer for frozen vegetables and freezer for frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to: Residents Affected - Some 1. Follow their policy and procedure titled Freezer Storage regarding maintaining a temperature of 0-degree Fahrenheit (F- unit of measurement) or lower . This failure had the potential to expose residents at risk for food-borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites). Findings: During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees Fahrenheit (F- unit of measurement) and the reach in freezer for meat products was reading at 24 degrees F. DM stated the kitchen personnel just removed some food items from the freezers that was why the temperatures are not 0-degree F on both freezers. During an interview on 4/8/2025, 2:15 p.m. with an unnamed technician (UT), the UT stated that they were called to fix the freezers around noontime today because the temperatures were high. Observed the freezer's temperature was 10 degrees F for frozen vegetables and freezer for frozen meat products was 18 degrees F. During an observation on 4/9/2025, at 12:05 p.m. with DM, reach in freezer temperature for frozen vegetables was 10 degrees F. Observed the freezer was empty. During an interview on 4/9/2025, at 12:10 p.m. and subsequent interview on 4/9/2025, at 1:17 p.m. with DM, DM stated he was aware the temperature of the freezer for the frozen vegetables was not maintained at 0-degree F or below since yesterday. DM stated he was monitoring the temperature of the freezer and was waiting for the temperature to go down to 0 degree but did not happen. DM stated the Registered Dietician (RD),and the Administrator (ADM) were aware the reach in freezer for vegetables was not maintaining its proper temperature. DM stated they threw away some of the frozen food items at around 9:00 a.m. today but the kitchen used the vegetables from the non-working freezer for the stir fry vegetables for lunch. DM stated residents could be at risk for unsafe food because of the vegetables used for the stir fry vegetables were not properly stored in the freezer. During a review of facility's Freezer Temperature Log for vegetables, the A.M. Temperature log of the freezer indicated a temperature of 10 degrees F on 4/9/2025. During an interview on 4/9/2025, at 12:51 p.m. with Dietary Aide (DA 1), DA 1 stated the DM told him to throw away the vegetables , and some breads from the freezer around 9:00 a.m. today and at that time the temperature of the freezer was 10 degrees F. DA 1 stated the vegetables used for the stir fry for lunch came from the freezer that was reading 10 degrees F. DA 1 stated the proper temperature to store frozen vegetables is 0 degree F to ensure freshness of food and to prevent bacterial growth that could place resident at risk for food borne illness. 055123 Page 30 of 31 055123 04/11/2025 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0908 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/9/2025, at 12:50 p.m. with [NAME] (CK1), CK 1 stated the temperature of the freezer for the vegetables at around 4:00 a.m. was 10 degrees F. CK 1 stated that he pulled out broccoli, carrots, zucchini and cauliflower from the non-working freezer to prepare for the day's meal. CK 1 stated all the vegetables that was served for lunch was from the non-working freezer. CK 1 stated residents could get sick from consuming the food if the vegetables were not stored properly in the freezer. Residents Affected - Some During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the temperature log of the freezer might not be reliable because it all indicated the temperatures are 0-degree F and the situation that could be going on for days. RD stated they should have discarded everything in the freezer because the facility does not know how long it had not been working. RD stated she is aware not all the food items stored in the non-working freezer was thrown away and was served for lunch today. During an interview on 4/9/2025, at 2:24 p.m. with Maintenance Supervisor, MS stated he was made aware yesterday by the DM about the non-working freezer. MS stated they started emptying the food items in the freezer this morning and placed some of the food items in the other freezer. He said he would call the technician if the freezer needs repair and he does not do maintenance of the freezers. During a telephone interview on 4/9/2025, at 2:14 p.m. with Administrator (ADM), ADM stated when the freezer's temperature was over zero despite maintenance, the kitchen personnel should have discarded the food items stored in the freezer. ADM stated residents could get food poisoning from consuming the food that came from the freezer. During a review of facility's policy and procedure (P&P) titled Preventive Maintenance Policy dated 07/2023, the P &P indicated the facility considers a Preventative Maintenance Program for all physical plant systems and equipment in all departments to eliminate and prevent unsafe environments. During a review of facility's P&P titled Freezer Storage, the P&P indicated the freezer should be maintained at a temperature of 0-degree F and freezer should be recorded twice daily. 055123 Page 31 of 31