Health inspection·November 26, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to treat one of three sampled residents (Resident 2) with dignity when the staff removed her indwelling urinary Foley catheter. * The facility failed to get permission from Resident 2 for multiple staff to be present during the Foley catheter removal. This failure had the potential to negatively affect Resident 2's well-being. Findings: Review of the facility's P&P titled Resident Rights revised 10/2009 showed the Federal and state laws guarantee certain basic rights to all residents of this facility which includes to choose a physician and treatment, and participate in decisions and care planning. Our facility will make every effort to exercise his/her rights to assure the resident is always treated with respect, kindness, and dignity. Review of the facility's P&P Titled Quality of Life-Dignity revised 10/2009 showed the staff members shall promote, maintain, and protect the residents' privacy, including bodily privacy during assistance with personal care and during treatment procedures. Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. On 11/19/24 at 1032 hours, an interview was conducted with Resident 2. Resident 2 stated on 11/16/24, two male and one female staff came into her room to remove her indwelling urinary foley catheter. Resident 2 stated she felt it did not take three people to remove the indwelling urinary Foley catheter, and the staff were treating her like a body and not as a person. On 11/19/24 at 1401 hours, a follow-up interview was conducted with Resident 2. Resident 2 stated when the staff came to remove her indwelling urinary Foley catheter, the staff did not ask her permission, and it was more like an announcement. Resident 2 further stated the staff did not ask her permission for the other staff to be present when removing her indwelling urinary Foley catheter. Resident 2 stated she felt upset, embarrassed, violated, and caused her to cry afterwards. On 11/19/24 at 1508 hours, an interview was conducted with LVN 2. LVN 2 stated she went in Resident 2's room to help LVN 4 and CNA 4 remove the indwelling urinary Foley catheter. LVN 2 stated Resident 2 requested for LVN 2 to remove it since the morning nurse was a male staff. When asked who was Page 1 of 6 555027 555027 11/26/2024 Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few present during the procedure, LVN 2 stated the three of us. When asked if Resident 2 was crying, LVN 2 stated Resident 2 was crying afterwards and stated she was shocked because the two gentlemen came in. When asked if Resident 2 should have been asked for the permission to have male staff present in the room when performing the procedure, LVN 2 stated, yeah I should have. On 11/21/24 at 1225, an interview was conducted with CNA 4. CNA 4 stated, we told Resident 2 there was an order from the physician for the indwelling urinary foley catheter to be removed. When asked who was present in the room during the procedure, CNA 4 stated two other charge nurses LVNs 2 and 4. When asked if Resident 2 was asked permission if all the three staff members can be present during the procedure, CNA 4 stated no, we just asked if it was okay to remove the indwelling urinary foley catheter. On 11/21/24 at 1557, an interview was conducted with LVN 4. LVN 4 stated he helped Resident 2 back in the bed for the procedure along with two other staff members. LVN 4 stated, Resident 2 asked why they were all there and stated it would not take three people to take the indwelling urinary catheter out. When asked if Resident 2 was asked for permission for all the three staff members to be present, LVN 4 stated I did not think so. On 11/22/24 at 1406 hours, an interview was conducted with the DSD. The DSD stated if the resident was uncomfortable with male staff being present in the room during the removal of the indwelling urinary foley catheter, they should have asked for permission first. The DSD stated it usually only takes one licensed nurse to remove an indwelling urinary foley catheter and one staff member should have left. On 11/22/24 at 1612 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

F755 - D Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications were administered as ordered for one of three sampled residents (Resident 2). * The facility failed to ensure the medications scheduled for 0900 hours were administered to Resident 2 timely. This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered within one hour of their prescribed time unless otherwise specified (for example before and after meal orders). Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. Resident 2 had a diagnosis of muscle spasms, hypertension, multiple sclerosis, and osteoarthritis. On 11/19/24 at 1005 hours, an interview was conducted with Resident 2. Resident 2 stated she had not received her knee patch and meloxicam (nonsteroidal anti-inflammatory medication) for her left 555027 Page 2 of 6 555027 11/26/2024 Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648

F 0557 knee pain. Level of Harm - Minimal harm or potential for actual harm On 11/19/24 at 1014 hours, an observation was conducted with LVN 1, when LVN 1 answered Resident 2's call light. Resident 2 stated to LVN 1 that she had not received her morning medications yet. Resident 2 stated the physical therapy already came by, but I can't do anything yet until I get my medications. LVN 1 replied to Resident 2, I haven't given them yet, because I'm still passing out meds. We can put on your patch now. Residents Affected - Few Review of Resident 2's MAR for November 2024 showed physician's order for the following medications scheduled to be administered at 0900 hours: - meloxicam oral tablet 15 mg-give one tablet by mouth one time a day for pain. - lidocaine external patch 4% apply to affected area topically one time a day for pain management. - lidocaine external patch 5% apply to left knee topically one time a day for pain management. - gabapentin oral capsule 300mg-give 300 mg by mouth three times a day for neuropathy (nerve pain). - calcium plus vitamin D3 oral tablet 600-10 mg-mcg-give one tablet one time a day for supplement. - hydrocortisone tablet 5 mg-give two tablets by mouth one time a day for inflammation. - amlodipine besylate tablet 10 mg-give one tablet by mouth one time a day for hypertension (high blood pressure). - ascorbic acid oral tablet 250 mg-give one tablet by mouth one time a day for supplement. - losartan potassium oral tablet 100 mg give one tablet by one dime a day for hypertension. - baclofen tablet 20 mg give one tablet by mouth four times a day for muscle spasms. - tizanidine HCL tablet 4 mg give one tablet by mouth one time a day for muscle relaxant. - multiple vitamin tablet-give one tablet by mouth one time a day for supplementation. - oxybutynin chloride ER tablet extended release 24-hour 10 mg give one tablet two times a day for OAB (overactive bladder). Review of Resident 2's Medication Admin Audit Report for 11/19/24, showed the following medications were administered at 1030 hours: - lidocaine external patch 4% - lidocaine external patch 5% - gabapentin oral capsule 300mg-give 300 mg - calcium plus vitamin D3 oral tablet 600-10 mg-mcg 555027 Page 3 of 6 555027 11/26/2024 Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648

F 0557 - hydrocortisone tablet 5 mg Level of Harm - Minimal harm or potential for actual harm - amlodipine besylate tablet 10 mg - baclofen tablet 20 mg Residents Affected - Few - tizanidine HCL tablet 4 mg - multiple vitamin tablet - oxybutynin chloride ER tablet extended release 24-hour 10 mg Further Review of Resident 2's Medication Admin Audit Report showed the ascorbic acid was administered at 1029 hours and meloxicam and losartan potassium were administered at 1031 hours. On 11/16/24 at 1020 hours, an interview was conducted with LVN 1. LVN 1 verified Resident 2's medications were administered late, more than one hour of the prescribed time (at 0900 hours) to be administered. On 11/22/24 at 1612 hours, an interview was conducted with the DON. The DON was made ware and acknowledged the above findings. 555027 Page 4 of 6 555027 11/26/2024 Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications were administered as ordered for one of three sampled residents (Resident 2). * The facility failed to ensure the medications scheduled for 0900 hours were administered to Resident 2timely. This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered within one hour of their prescribed time unless otherwise specified (for example before and after meal orders). Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. Resident 2 had a diagnosis of muscle spasms, hypertension, multiple sclerosis, and osteoarthritis. On 11/19/24 at 1005 hours, an interview was conducted with Resident 2. Resident 2 stated she had not received her knee patch and meloxicam (nonsteroidal anti-inflammatory medication) for her left knee pain. On 11/19/24 at 1014 hours, an observation was conducted with LVN 1, when LVN 1 answered Resident 2's call light. Resident 2 stated to LVN 1 that she had not received her morning medications yet. Resident 2 stated the physical therapy already came by, but I can't do anything yet until I get my medications. LVN 1 replied to Resident 2, I haven't given them yet, because I'm still passing out meds. We can put on your patch now. Review of Resident 2's MAR for November 2024 showed physician's order for the following medications scheduled to be administered at 0900 hours: - meloxicam oral tablet 15 mg-give one tablet by mouth one time a day for pain. - lidocaine external patch 4% apply to affected area topically one time a day for pain management. - lidocaine external patch 5% apply to left knee topically one time a day for pain management. - gabapentin oral capsule 300mg-give 300 mg by mouth three times a day for neuropathy (nerve pain). - calcium plus vitamin D3 oral tablet 600-10 mg-mcg-give one tablet one time a day for supplement. - hydrocortisone tablet 5 mg-give two tablets by mouth one time a day for inflammation. - amlodipine besylate tablet 10 mg-give one tablet by mouth one time a day for hypertension (high blood pressure). 555027 Page 5 of 6 555027 11/26/2024 Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648

F 0755 - ascorbic acid oral tablet 250 mg-give one tablet by mouth one time a day for supplement. Level of Harm - Minimal harm or potential for actual harm - losartan potassium oral tablet 100 mg give one tablet by one dime a day for hypertension. - baclofen tablet 20 mg give one tablet by mouth four times a day for muscle spasms. Residents Affected - Few - tizanidine HCL tablet 4 mg give one tablet by mouth one time a day for muscle relaxant. - multiple vitamin tablet-give one tablet by mouth one time a day for supplementation. - oxybutynin chloride ER tablet extended release 24-hour 10 mg give one tablet two times a day for OAB (overactive bladder). Review of Resident 2's Medication Admin Audit Report for 11/19/24, showed the following medications were administered at 1030 hours: - lidocaine external patch 4% - lidocaine external patch 5% - gabapentin oral capsule 300mg-give 300 mg - calcium plus vitamin D3 oral tablet 600-10 mg-mcg - hydrocortisone tablet 5 mg - amlodipine besylate tablet 10 mg - baclofen tablet 20 mg - tizanidine HCL tablet 4 mg - multiple vitamin tablet - oxybutynin chloride ER tablet extended release 24-hour 10 mg Further review of Resident 2's Medication Admin Audit Report showed the ascorbic acid was administered at 1029 hours and meloxicam and losartan potassium were administered at 1031 hours. On 11/16/24 at 1020 hours, an interview was conducted with LVN 1. LVN 1 verified Resident 2's medications were administered late, more than one hour of the prescribed time (at 0900 hours) to be administered. On 11/22/24 at 1612 hours, an interview was conducted with the DON. The DON was made ware and acknowledged the above findings. 555027 Page 6 of 6