Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beachside Post Acute during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, and limited mobility sustained an acute distal femur fracture of unknown cause. The facility became aware of the injury through X-ray results but did not report the unusual occurrence to CDPH within the required 24-hour timeframe, as confirmed by staff interviews and record review. This delay was not in accordance with facility policy for reporting injuries of unknown origin.
The facility's kitchen staff, including a dietary supervisor assistant and a dietary aide, failed to follow proper food thawing procedures, leading to a deficiency. A box of chicken was improperly thawed and refrozen, contrary to facility policy and FDA guidelines. This placed 99 out of 106 residents at risk for foodborne illness due to potential bacterial growth.
The facility failed to maintain sanitary food storage and handling practices, risking foodborne illnesses for residents. Observations included expired cottage cheese, incomplete temperature logs, and improper thawing and refreezing of food. Additionally, the ice machine was inadequately cleaned, with no cleaning log maintained, increasing the risk of contamination.
A facility failed to maintain accurate and complete clinical documentation for two residents. One resident's records inaccurately documented IV access and fluids, despite observations confirming the absence of IV access. Another resident's records were incomplete regarding Restorative Nursing Aide services, with a missing RNA flow sheet. These deficiencies highlight a failure to adhere to documentation standards, potentially impacting resident care.
The facility failed to implement proper infection control measures, as evidenced by improper PPE use and maintenance of equipment. A resident on Enhanced Barrier Precautions (EBP) had a visitor not wearing PPE, and staff did not follow proper PPE protocols, increasing the risk of infection spread. Additionally, padded side rails on beds were inadequately maintained, with cracked duct tape exposing foam, compromising disinfection efforts.
A resident with a history of amputation, muscle weakness, and dependence on supplemental oxygen was found in a state of anxiety and hyperventilation due to difficulty breathing. The call light was out of reach, preventing the resident from calling for help as her oxygen supply was running low. Facility staff confirmed that the call light should have been within reach, as per the facility's policy and the resident's care plan.
A facility failed to monitor a resident's range of motion (ROM) in both legs by not performing an annual Joint Mobility Screen (JMS) as per policy, potentially leaving the resident without proper monitoring for 21 months. The resident had impaired ROM in hips, knees, and ankles, and the PT discharge recommended PROM exercises. However, the JMS did not assess the legs, leading to a gap in monitoring. Interviews confirmed the JMS was meant to track ROM decline and prevent complications, but the facility did not adhere to its policy.
A resident in hospice care with dementia and other conditions lost their dentures, and the facility failed to provide prompt dental services or adjust the diet to ensure adequate nutrition. Despite significant weight loss and poor oral intake, the resident's diet remained unchanged, and there was a lack of communication among staff regarding the resident's needs. The facility's policy for prompt dental referral was not effectively implemented.
A resident in hospice care with dementia and other conditions was not provided with her preferred puree diet, despite her inability to consume solid foods. The facility's staff, including CNAs and an LVN, were aware of her preference but failed to communicate this to the RD or update her care plan. The DON was also unaware of the resident's needs, which led to inadequate dietary accommodations.
A resident with dementia and osteoporosis sustained a femur fracture of unknown origin, which was not reported to the CDPH as required by facility policy. The DON did not report the injury, believing it was unavoidable due to the resident's condition. The Administrator later acknowledged the reporting failure, which hindered timely investigation by CDPH.
A resident with dementia and osteoporosis sustained a femur fracture of unknown origin, which was not investigated by the facility. Despite the resident's physician attributing the fracture to osteoporosis, the facility's policy required an investigation for injuries of unknown origin. The administrator acknowledged the need for an investigation to determine the root cause.
Failure to Timely Report Unexplained Fracture to State Agency
Penalty
Summary
The facility failed to follow its abuse prevention and unusual occurrence reporting policies when it did not report an acute, new distal femur fracture of unknown cause for a resident to the State Survey Agency (CDPH) within 24 hours of becoming aware of the incident. The resident, who had diagnoses including age-related osteoporosis, dementia, and right knee contracture, was dependent on assistance for activities of daily living and lacked capacity to make decisions. The fracture was identified via X-ray, and the results were reported to the facility on 5/4/2025. However, the facility did not notify CDPH of the unusual occurrence until 5/7/2025, exceeding the required 24-hour reporting timeframe. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the delay in reporting was not in accordance with facility policy, which requires reporting of such incidents within 24 hours. Review of the facility's policies further supported that all unusual occurrences and injuries of unknown origin must be reported promptly to appropriate authorities. The failure to report the incident in a timely manner was acknowledged by staff and documented in the facility's records.
Improper Thawing Practices in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff, including the dietary supervisor assistant (DSA) and dietary aide (DA 1), were competent in following the facility's food thawing policies. During an observation, a box of frozen chicken was found sitting by the food preparation sink, appearing partially thawed with wet cardboard from thawing juices. The DSA instructed DA 1 to place the chicken back into the main freezer, which was against the facility's policy. Later, the DSA instructed staff to remove the chicken from the freezer and place it back in the sink for thawing, initially without running water, which was also against the policy. The dietary supervisor (DS) later intervened, stating that refreezing chicken was not allowed. Interviews with DA 1 and the DSA revealed a lack of understanding of proper thawing procedures, as DA 1 followed the DSA's incorrect instructions despite knowing they were wrong. The facility's policies indicated that food should not be thawed at room temperature and should be submerged in cold running water. The U.S. Food and Drug Administration food code was also referenced, highlighting the risks of improper thawing, which can lead to bacterial growth and foodborne illness. This deficiency placed 99 out of 106 residents at risk for developing foodborne illnesses.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 99 out of 106 residents. Observations revealed that cottage cheese in the reach-in refrigerator was past its use-by date, and the temperature log for the walk-in refrigerator was not consistently filled out. Additionally, improper food handling practices were noted, such as thawed frozen waffles being returned to the freezer and raw chicken being improperly thawed and refrozen. The dietary staff did not adhere to proper thawing techniques, as evidenced by chicken being left to thaw in a sink without running water. The dietary supervisor assistant instructed staff to refreeze partially thawed chicken, which was against facility procedures. The dietary supervisor later confirmed that thawed items should not be refrozen and should be placed in the refrigerator to continue thawing. These practices increased the risk of bacterial growth and potential food contamination. The facility's ice machine was also found to be inadequately maintained, with dust and a black substance observed in the upper portion. The maintenance supervisor admitted to cleaning the ice machine every six months but did not keep a cleaning log. The infection preventionist nurse highlighted the potential risk of illness due to the unclean ice machine. The facility's policies and procedures, as well as the U.S. Food and Drug Administration food code, were not followed, contributing to the deficiencies observed.
Inaccurate and Incomplete Clinical Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for two residents, leading to deficiencies in their care records. For one resident, the documentation related to intravenous (IV) access and fluids was inaccurate. The resident was admitted with severe cognitive impairment and conditions such as seizures and acute kidney failure. Despite physician orders indicating the completion of IV fluids on a specific date, subsequent notes inaccurately documented the resident as still receiving IV fluids. Observations confirmed the absence of IV access, and interviews with nursing staff revealed the documentation errors, highlighting the importance of accurate records to prevent infection risks and ensure proper hydration assessment. Another resident with limited range of motion and mobility issues had incomplete clinical records regarding the provision of Restorative Nursing Aide (RNA) services. The resident, diagnosed with dementia and functional quadriplegia, required passive range of motion exercises and the application of splints as per physician orders. However, the RNA flow sheet for a specific month was missing from the resident's clinical record. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed the absence of the flow sheet, indicating incomplete records for the resident's RNA services. The facility's policy and procedure on charting and documentation emphasized the need for complete and accurate medical records for all services provided to residents. The deficiencies in documentation for both residents reflect a failure to adhere to these standards, resulting in incomplete and inaccurate clinical records. This lack of proper documentation could potentially impact the quality of care provided to the residents.
Infection Control Deficiencies in PPE Use and Equipment Maintenance
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several observations and interviews. In the case of Resident 260, who was on Enhanced Barrier Precautions (EBP) due to a gastrostomy and an unstageable pressure ulcer, a visitor was observed not wearing the required Personal Protective Equipment (PPE) while interacting with the resident. Licensed Vocational Nurses (LVN) 2 and 3, who attended to Resident 260, did not instruct the visitor to wear PPE and were observed doffing their PPE incorrectly, potentially leading to self-contamination. The facility's policy and CDC guidelines were not followed, as gloves were not removed first, which is crucial to prevent the spread of infection. In another instance, Resident 8, who was also on EBP due to a gastrostomy and stage 3 pressure ulcer, received care from LVN 1, LVN 4, and CNA 1, none of whom wore the appropriate PPE. LVN 1 and CNA 1 entered the room and provided care without donning any PPE, while LVN 4 only wore gloves. This lack of adherence to PPE protocols during high-contact care activities increased the risk of cross-contamination and infection spread among residents and staff. Additionally, the facility failed to maintain the integrity of padded side rails on the beds of four residents, which were covered with duct tape that was cracked and peeling, exposing the foam underneath. This compromised the ability to properly disinfect the side rails, as the foam is a porous material that cannot be sanitized effectively. The maintenance supervisor acknowledged the issue, stating that the duct tape was used as a temporary measure, but it was not recommended by the bed manufacturer. The housekeeping supervisor confirmed that the exposed foam posed a risk for bacterial growth, as the disinfectant used was only effective on hard, non-porous surfaces.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for Resident 8, which had the potential to prevent the resident from receiving necessary care and services in a timely manner. Resident 8, who had a history of left leg above knee amputation, muscle weakness, dependence on supplemental oxygen, and a stage 3 pressure ulcer, was observed sitting in a wheelchair and experiencing hyperventilation and anxiety due to difficulty breathing. The call light was clipped on the left side of the bed, out of reach for Resident 8, who expressed fear and helplessness due to her inability to call for help as her oxygen supply was running low. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the call light should have been within reach at all times to accommodate residents' needs promptly. The facility's policy and procedure on answering call lights also indicated that the call light should be within easy reach of residents. Resident 8's care plan, which highlighted her risk for falls and impaired balance, also specified that the call light should be kept within easy reach, yet this was not adhered to, leading to the deficiency.
Failure to Monitor Resident's Range of Motion
Penalty
Summary
The facility failed to monitor the range of motion (ROM) in both legs of a resident with limited mobility, as they did not perform an annual Joint Mobility Screen (JMS) on the specified date in accordance with their policy. This oversight potentially left the resident without proper monitoring for 21 months, from the discharge from Physical Therapy (PT) to the next scheduled JMS. The resident, who was initially admitted in 2019 and readmitted in 2023, had diagnoses including dementia, functional quadriplegia, and contractures in multiple joints. The resident's PT evaluation in July 2023 indicated impaired ROM in both hips, knees, and ankles, with specific limitations noted in hip flexion, knee flexion, and ankle dorsiflexion and plantarflexion. The PT discharge summary recommended passive range of motion (PROM) exercises for both legs, except the right knee, to be performed by a Restorative Nursing Aide (RNA) five times per week. However, the annual JMS conducted in April 2024 did not assess the ROM in the resident's legs, leaving a gap in monitoring. Interviews with the Director of Rehabilitation (DOR) and the Director of Nursing (DON) confirmed that the JMS was intended to track ROM decline and prevent complications such as contractures and pressure injuries. The facility's policy required annual JMS for each resident, but the resident's legs were not assessed since the PT discharge, leading to a prolonged period without evaluation. The facility's policy and procedure indicated that residents with limited ROM should receive appropriate services to maintain or improve mobility, which was not adhered to in this case.
Failure to Provide Prompt Dental Services and Adequate Nutrition
Penalty
Summary
The facility failed to provide prompt dental services for a resident after the loss of dentures on 9/10/24. The resident, who was admitted under hospice care with multiple diagnoses including dementia and heart failure, was dependent on assistance for daily activities and had a mechanical soft diet ordered. Despite the loss of dentures, there was no dental consult ordered immediately, and the resident did not receive a dental evaluation until 9/25/24. During this period, the resident was unable to eat the mechanical soft diet adequately, leading to poor oral intake and significant weight loss. The facility's records indicate that the resident was referred to a dentist on 9/11/24, but the dental progress notes show that no treatment was indicated due to the resident's medical condition. The resident's diet remained unchanged despite the inability to chew properly, and there was no documentation of any interventions to ensure adequate nutrition. The interdisciplinary team discussed the resident's condition on 10/16/24, noting the weight loss, but did not adjust the diet consistency. Interviews with staff revealed a lack of communication and coordination regarding the resident's dietary needs and dental status. The Registered Dietitian was not informed of the denture loss and thus did not adjust the diet to a puree consistency, which could have been more suitable given the resident's inability to chew. The Director of Nursing was aware of the denture loss but did not initiate a change in diet consistency. The facility's policy required prompt referral to a dentist for lost dentures, but this was not effectively implemented, resulting in a delay in addressing the resident's nutritional needs.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident received food according to her preferences, which led to a deficiency in care. The resident, who was admitted under hospice care with multiple diagnoses including dementia and heart failure, was on a mechanical soft diet. However, it was observed that she preferred puree food, as she had no teeth and struggled with solid foods. Despite this preference, there was no discussion or action taken to change her diet to accommodate her needs. During observations and interviews, it was noted that the resident ate very little of her meals, consuming only about 25% of her food intake. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) both acknowledged the resident's preference for puree food, yet this information was not communicated to the Registered Dietitian (RD) or reflected in the resident's care plan. The RD stated that if they had been informed of the resident's chewing difficulties, they would have downgraded the diet to a puree consistency to prevent the risk of weight loss. The Director of Nursing (DON) was unaware of the resident's dietary preferences and stated that a Speech Language Pathologist (SLP) would have been consulted to evaluate the resident if this information had been known. The facility's policy on resident food preferences requires staff to document dietary preferences and communicate any conflicts with therapeutic diets, but this was not adhered to in the case of this resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for a resident who sustained a moderately displaced fracture of the distal diaphysis of the femur. The resident, who was admitted with diagnoses including encephalopathy, dementia, and generalized weakness, was unable to make consistent and reasonable decisions. On a specific date, the resident was noted to be groaning and screaming during assistance with lower body dressing, and swelling was observed in the right knee. A stat X-ray revealed a moderately displaced fracture, and the resident was subsequently transferred to a General Acute Care Hospital for evaluation and treatment. The Director of Nursing Services (DON) did not report the injury to CDPH, citing the physician's documentation that the fracture was unavoidable due to the resident's osteoporosis. However, the facility's policy requires that any injury of unknown source be reported immediately to the Administrator and state officials. The Administrator acknowledged that the facility should have reported the injury to CDPH. This oversight resulted in the inability of CDPH to investigate the injury in a timely manner, potentially leading to the loss of relevant facts related to the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who sustained a moderately displaced fracture of the distal diaphysis of the femur. The resident, who was admitted with diagnoses including encephalopathy, dementia, and generalized weakness, was unable to make consistent and reasonable decisions. On a specific date, the resident was noted to be groaning and screaming during assistance with lower body dressing, and swelling was observed in the right knee. A stat X-ray revealed the fracture, and the resident was subsequently transferred to a general acute care hospital for evaluation and treatment. The Director of Nursing Services did not investigate the injury, citing the resident's osteoporosis as the reason for the fracture being deemed unavoidable by the resident's physician. However, the facility's policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation, revised in April 2021, mandates that all reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility management. The facility's administrator acknowledged that an investigation should have been conducted to determine the root cause of the injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,142 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Torrance Memorial Med Ctr Snf/dp | 0.8 mi | — | 3 | 0 |
| Del Amo Gardens Care Center | 1.2 mi | — | 14 | 0 |
| Bay Crest Care Center | 1.5 mi | — | 45 | 1 |
| Torrance Care Center West, Inc | 1.5 mi | — | 7 | 0 |
| Providence Little Co Of Mary Transitional Care Ctr | 1.6 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Beachside Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.