Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Long Beach Post Acute during CMS and state inspections, most recent first.
Failure to Obtain Informed Consent for Adderall: A resident with ADHD, anxiety, and major depression with psychotic symptoms received Adderall 20 mg daily without documented informed consent. The resident was cognitively intact and stated she was not told why the dose changed from her prior regimen or reviewed the medication with a doctor. The record showed the psychotropic medication was ordered and administered daily, while the RNS confirmed no informed consent was present.
A resident with intact cognition and diagnoses including ADHD, functional dyspepsia, and constipation filed a grievance about being served salads with processed deli meat instead of chicken only. Although the grievance was marked resolved, the dietary dept was not properly notified, the Dietary Supervisor and RD were unaware of the complaint, and the resident continued to receive the unwanted processed meat on her salads after the grievance was filed.
Inaccurate MDS and Care Plans Omitted Active Diagnoses: A resident’s MDS, admission diagnosis list, nutrition assessment, and care plans failed to include documented autism, prior eating disorder history, gastric sleeve surgery, loose tooth, chewing difficulty, and food intolerances. The RD relied on the face sheet, diagnosis list, and MD orders without reviewing hospital records, and the MDS nurse stated he did not enter the diagnoses because he believed the resident was not being monitored for them, even though the resident reported difficulty eating certain foods and needing a consistent tolerable diet.
Failure to develop and implement a person-centered care plan for a resident’s autism and bathing barriers. The resident had anxiety, depression, insomnia, nightmare disorder, ADHD, intact cognition, and needed supervision or touching assistance with ADLs. The resident’s psych eval identified autism, and the resident requested individualized communication and therapy approaches, but staff did not include autism in the care plan. Staff also treated shower refusals as a preference for in-room hygiene rather than documenting and addressing them in the care plan, despite the resident’s stated bathing preferences and repeated refusal of showers.
A resident with intact cognition and ADL assistance needs repeatedly refused scheduled showers, stating the shower area lacked privacy, was dirty, and allowed male staff and male residents to be present or observe. CNA staff reported the refusals to the charge nurse, but the reason for refusal was not identified or documented, and RN staff said the resident’s in-room washing was treated as a preference rather than a refusal. IDT notes and care plans did not address the shower refusals, despite the resident continuing to complete hygiene in the room with wipes instead of receiving showers.
A resident with autism, prior gastric sleeve surgery, a loose tooth, and a history of eating disorders had an incomplete nutritional assessment that did not capture key medical and dental information. The RD relied on limited records, the DS did not complete the admission assessment, and the resident’s salad preferences were not consistently followed, with meals repeatedly served with diced processed meat despite repeated requests for chicken only and no processed meat.
Incomplete documentation of therapy refusals and discontinuation notice: A resident with muscle wasting, atrophy, abnormal gait, pain, and intact cognition received PT/OT for ADL and mobility dysfunction. Staff documented therapy continuation and later OT discontinuation, but the chart did not show that the resident was notified of refusals, educated on how refusals affected skilled coverage, or clearly informed when OT ended. The ABN and NOMNC were issued without documentation that the resident or RP signed them, and interviews showed staff relied on goals met/non-compliance while the resident disputed that she refused therapy and said she only requested not to work with a specific therapist.
Food storage practices were not followed when an opened container of sesame oil was found without an open date and five prepared bowls of dry cereal were found without a date prepared. The DS confirmed the missing labels, and the RD stated opened food items should be dated and labeled. Facility policy required opened and prepared foods to be labeled and dated.
Missing Care Plan for Risperdal Therapy: A resident with paranoid schizophrenia, schizoaffective disorder, and fluctuating decision-making capacity had Risperdal ordered for paranoid schizophrenia and auditory hallucinations, but RN and DON interviews confirmed no documented, person-centered care plan was developed or implemented for the psychotropic medication. The facility policy stated behaviors were to be addressed in progress notes and on the resident-centered care plan.
Failure to revise a resident’s impaired communication care plan. A resident who was deaf and non-verbal, with diagnoses including hearing loss and IPAN, had intact cognition and was independent with ADLs, but the RN Supervisor stated there was no communication/language care plan in the chart. The DON later reviewed an impaired communication care plan and stated the target date should have been updated; the facility policy required care plans to be reviewed and revised at least quarterly and on an ongoing basis.
A resident admitted with a CPAP machine and a history of sleep apnea stated he told nursing staff on admission that he needed CPAP use and was missing his mask. However, the chart lacked documentation that the report was made or that an RN admission assessment was completed for CPAP use. Staff interviews confirmed the absence of documentation, and the DON stated a licensed nurse should have documented the resident’s CPAP history.
A resident with schizophrenia and anxiety disorder eloped from a facility due to inadequate supervision during a smoke break. The resident was last seen on the patio, where only one staff member was present with about 20 residents. The facility's monitoring log showed no designated staff on the patio after 8:30 p.m., and the resident was found at a family residence over eight hours later.
The facility failed to label opened pasta bags and improperly thawed diced beef, risking food-borne illnesses for 63 residents. Opened pasta was found without an open date, and diced beef was thawed in still water instead of under running water, contrary to facility policies.
The facility failed to document the administration of a narcotic for a resident and the receipt of home medications for another. A discrepancy in the narcotic count for Lorazepam was found, and an unopened bag of unidentified medications lacked documentation. These failures violated the facility's policies on controlled medication documentation and receipt of medications.
A facility failed to provide trauma-informed care for a resident with PTSD, lacking a care plan that identified triggers and interventions. Despite assessments indicating past traumatic events, the resident's care plans did not address these needs, as confirmed by the ADON and DON.
A resident with multiple health conditions required dental crowns but did not receive follow-up care after initially refusing treatment. Despite expressing a desire for the dental work to be completed, there were no further dental notes or follow-ups. The facility's policy for dental evaluations was not adhered to, and the lack of documentation and follow-up was confirmed by staff interviews.
A resident with dysphagia was given cookies instead of a pureed diet as prescribed, leading to potential choking risks. The CNA was initially unaware of the resident's dietary needs, and the SLP confirmed that cookies were inappropriate. The DON highlighted the importance of following physician orders to prevent aspiration.
A facility failed to document the required 15-minute visual monitoring of a resident with schizophrenia, depressive episodes, and generalized anxiety disorder. Despite CNAs closely monitoring the resident, there was no documentation in the medical records, contrary to the care plan and facility policies. The ADON and DON confirmed the lack of documentation, highlighting a deficiency in maintaining accurate clinical records.
Failure to Obtain Informed Consent for Adderall
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering amphetamine-dextroamphetamine (Adderall) to one resident. The resident was admitted with diagnoses including generalized anxiety disorder, major depressive disorder with psychotic symptoms, and ADHD. The history and physical documented that the resident had the capacity to understand and make decisions, and the MDS indicated cognition was intact. The resident’s psychiatric evaluation documented that she was receiving Adderall 20 mg daily as a psychotropic medication and that the plan was to continue it. The physician order summary showed an order for Adderall 20 mg by mouth once daily for ADHD, and the MAR showed the medication was administered daily from 3/21/2026 through 5/5/2026. During an IDT conference, the resident asked about the next psychiatric visit to discuss the Adderall dosing with the medical doctor. During interviews, the resident stated she had taken Adderall 20 mg three times daily before admission, but the facility gave it once daily and she had not been informed why the dose changed. She also stated she never signed an informed consent for Adderall or reviewed the dose with a doctor. The RNS reviewed the record and stated there was no informed consent for Adderall and that if it was considered a psychotropic medication, informed consent should have been completed before administration. The facility policy required the ordering physician, PA, or NP to obtain informed consent before initiating psychotherapeutic medication and to verify consent before administration.
Grievance Process Not Followed for Dietary Complaint
Penalty
Summary
The facility failed to follow its grievance process for a resident who had the capacity to understand and make decisions and whose cognition was intact. The resident had diagnoses including ADHD, functional dyspepsia, and constipation. Her assessment also indicated that snacks between meals were very important to her. She reported ongoing dietary concerns because she was being served food items she did not request and had already discussed her meal preferences with staff. The resident filed a grievance about being served salads with processed deli meat when she requested salads with chicken only. The grievance log showed the concern was marked resolved the next day, and the grievance form stated the resident’s dietary preferences were reviewed and updated, nursing staff were reminded to communicate preferences to dietary, and the dietary department was informed in person. The form also stated correct meals were provided and that the resident understood the corrective actions taken. However, the resident later stated she continued to receive processed deli meat on salads after the grievance was filed and that she had complained several times. During observation, the resident’s lunch tray included a salad with cheese, cucumbers, tomatoes, lettuce, carrots, and processed deli meat, and the resident stated this was the same meat she had repeatedly requested not be served. The Social Services Director stated she was informed of the grievance and followed up with the resident, but the Dietary Supervisor stated he did not receive the grievance form and was not aware of the complaint. The Registered Dietitian also stated she was unaware of the grievance. The Administrator stated the grievance process was completed but documentation was not provided, and also stated the facility did not complete the regular grievance process because it could not complete an IDT meeting with the resident.
Inaccurate MDS and Care Plans Omitted Active Diagnoses
Penalty
Summary
The facility failed to ensure that one resident’s MDS and related records accurately reflected active diagnoses and conditions documented in hospital and physician records. Resident 1 was admitted with diagnoses including anxiety, depression, insomnia, nightmare disorder, ADHD, functional dyspepsia, and constipation, and the H&P stated the resident had capacity to understand and make decisions. However, the MDS completed on 3/17/2026 did not include autism, a history of eating disorders, gastric sleeve surgery, or dental concerns, even though those conditions were documented in the resident’s psychiatric evaluation and hospital H&P. Record review showed that Resident 1’s GACH psychiatric evaluation documented autism and a past eating disorder history, and the GACH H&P documented gastric sleeve surgery in 2017 and a loose right front tooth. The admission diagnosis list did not include autism, gastric sleeve surgery, loose tooth, toothache, chewing problems, or eating disorder history. The nutrition risk assessment stated the resident had teeth or dentures in good condition and good food intake, and it did not identify loose teeth, gastric sleeve surgery, autism, eating disorder history, food intolerances, chewing problems, or swallowing problems. The resident’s care plans also did not reflect these conditions. The GI distress care plan addressed dyspepsia but did not include gastric sleeve history or food intolerance related to the surgery. The oral/dental care plan addressed loss of appetite, refusal to eat, and behavior, but did not include loose teeth, chewing difficulty, or the need for modified textures due to dental status. The nutrition care plan identified risk for malnutrition related to anxiety, depression, chronic pain, insomnia, alcohol abuse, and being overweight, but did not include gastric sleeve surgery, autism, chewing difficulty, food intolerances, or history of eating disorders. During interview, the resident stated she had difficulty eating facility food, requested salads with chicken only, and said diced deli meat upset her stomach and became stuck in her loose teeth. The RD stated she relied on the face sheet, admission diagnosis list, and physician orders for the admission nutritional assessment and did not review hospital discharge records or progress notes. The MDS nurse stated he did not enter autism, gastric sleeve surgery, or loose tooth on the diagnosis list because he believed the resident was not being monitored for those diagnoses, and acknowledged that leaving them off affected the resident’s care.
Failure to Care Plan Autism and Bathing Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident’s autism and for bathing preferences and barriers. The resident’s admission record showed diagnoses including generalized anxiety disorder, major depressive disorder, insomnia, nightmare disorder, and ADHD. The history and physical stated the resident had the capacity to understand and make decisions. The MDS indicated the resident’s cognition was intact and that the resident required supervision or touching assistance for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS also noted that choosing between a tub bath, shower, bed bath, or sponge bath and having snacks available between meals were very important to the resident. The resident’s psychiatric evaluation identified autism and a past history of eating disorders. In an email to the Administrator and Social Services Director, the resident requested that autism be included in the record and asked for care approaches related to autism, including advance notice, scheduled therapy times, a clear therapy plan before each session, staff identification by name and role, written communication when possible, a private setting for sensitive discussions, and assignment to therapy staff the resident could work with safely and calmly. During interviews, CNA staff stated the resident refused showers and that the resident’s showers were scheduled on Tuesdays and Saturdays, though showers could be offered any day. CNA staff reported the resident always refused showers when assigned to that CNA and that refusals were reported to the charge nurse. During review with the RN supervisor, it was stated that the resident declined showers and preferred to complete personal hygiene in the resident’s room, but these were not documented as refusals because that was considered the resident’s preference. The RN stated the care team should have been notified and the shower refusals should have been addressed in the care plan, and also stated the resident did not have a care plan for autism. The RN further stated staff were unaware of the autism diagnosis before the investigation and that knowing about autism would have changed the approach to care. The MDS nurse stated autism was not added to the diagnosis list because it was not in the physician’s notes, and that if it had been captured it would have been care planned with interventions. The facility policy required the interdisciplinary team to develop an individualized comprehensive care plan based on the resident’s assessment, started on admission and completed within seven days of assessment completion.
Failure to Address Repeated Shower Refusals and Hygiene Needs
Penalty
Summary
The facility failed to ensure staff consistently identified, documented, and addressed the reasons for one resident’s repeated refusals of scheduled showers, and failed to implement alternative approaches to provide adequate bathing and hygiene care. The resident was admitted with diagnoses including muscle wasting and atrophy, abnormal gait and mobility, generalized anxiety disorder, and ADHD. The resident’s H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated cognition was intact and that the resident required supervision or touching assistance from staff for bathing and personal hygiene. The MDS also noted that the resident’s preference to choose between a tub bath, shower, bed bath, or sponge bath was very important. During interview, the resident stated she did not take showers because there was no privacy in the shower room, men could be in the shower room with women, the shower room was dirty, the curtains did not close all the way, dirty linen was kept in the shower room, and a tall male staff member watched while residents showered. The resident stated she told staff she did not want men walking in unannounced and complained to the facility, but staff did not do anything. The resident stated she instead washed up in her room bathroom with baby wipes and was told, "You can take a shower if you want." Staff interviews and record review showed CNA staff reported the resident refused showers and that refusals were reported to the charge nurse, but the reason for refusal was not known. RN staff stated the resident declined showers and completed personal hygiene in her room, and that the showers were not documented as refusals because staff considered in-room personal hygiene to be the resident’s preference. RN staff acknowledged the IDT notes did not address shower refusals and the care plans did not address them. The facility policy required CNA documentation of bathing and personal hygiene and required approaches for residents who refused care, including notifying the licensed nurse and physician within the specified time frame.
Incomplete Nutritional Assessment and Unmet Food Preferences
Penalty
Summary
The facility failed to ensure the RD and DS completed a comprehensive and accurate nutritional assessment for one resident with multiple relevant conditions and preferences. The resident was admitted with diagnoses including ADHD, overweight, functional dyspepsia, and constipation, and records also showed intact cognition and a need for supervision or touching assistance with eating and other activities. Additional hospital and psychiatric records identified autism, a history of eating disorders, gastric sleeve surgery in 2017, a loose right front tooth after a fall, and prediabetes, but these details were not included on the admission diagnosis list, the nutrition risk assessment, or the admission nutritional assessment. The resident’s records also documented specific eating-related concerns and preferences. The care plan addressed GI distress, oral/dental issues, and nutrition risk, and the physician note recorded the resident’s statement that she could not eat and that her system did not accept food, along with a request for Ensure. The resident later stated she requested salads because they were something she could eat, but she wanted chicken only on her salads because diced deli meat upset her stomach and became stuck in her loose teeth. She stated the facility had sometimes prepared salads according to her preference, but not consistently, and she showed photographs of salads served with diced deli meat. During interviews, the RD stated she used the face sheet, diagnosis list, and physician orders to complete the admission nutritional assessment and did not use the hospital discharge notes. She stated she did not know the resident had loose teeth, gastric sleeve surgery, autism, or a history of eating disorders when she completed the assessment, and she acknowledged she should have reviewed more information and hospital records. The DS stated he did not complete the admission nutritional assessment, that the dental status section was not completed, and that the assessment did not show a chewing or swallowing problem. He also stated he documented resident preferences on a plate card and verbally relayed issues, but did not write a note when referring concerns to the RD. Staff interviews and record review showed the resident’s food preferences were discussed in IDT meetings and later posted in the kitchen, yet meals continued to be served with diced processed or deli-style meat despite the resident’s repeated requests for chicken only and no processed meat.
Incomplete documentation of therapy refusals and discontinuation notice
Penalty
Summary
The facility failed to ensure staff accurately documented when a resident refused therapy and when the resident was notified that therapy services were discontinued. The resident was admitted with diagnoses including muscle wasting and atrophy, abnormal gait and mobility, right leg pain, chronic pain, muscle spasm, and ADHD. The resident’s H&P documented that she had the capacity to understand and make decisions, and the MDS indicated intact cognition with supervision or touching assistance needed for multiple ADLs. The record showed PT/OT were ordered and continued for mobility and ADL dysfunction, with documentation that the resident had a high risk for functional impairment without therapy. Therapy notes and nursing notes reflected ongoing skilled services, including a telephone order to continue PT and OT and later a telephone order to discontinue skilled OT after that day. However, the nursing notes did not document that the resident was notified of the OT discontinuation, and the therapy record did not show documentation that the resident was notified of refusals or educated about how refusals affected continued skilled services. The clinical record also did not show an IDT meeting related to the therapy refusals before OT was discontinued or before the NOMNC was issued. The ABN and NOMNC indicated therapy/skilled services would end and that skilled care was no longer needed, but neither document showed that the resident had been informed of the refusals, educated about their effect on skilled coverage, or signed and dated the notices. During interviews, OT staff stated the resident was told therapy would end but that the conversation was not documented, and the PT/DOR stated therapy was discontinued because goals were met or due to non-compliance, while also stating no IDT meeting was completed. The resident stated she did not refuse therapy, only did not want to work with a specific therapy staff member, and she disputed any record indicating she refused rehabilitation or accepted custodial care.
Food Items Not Labeled or Dated in Storage
Penalty
Summary
The facility failed to ensure food was stored under sanitary conditions in one kitchen by not labeling an opened gallon container of sesame oil with an open date and by not labeling prepared bowl containers of dry cereal with a date prepared. During a concurrent observation and interview in the dry storage room, the Dietary Supervisor confirmed the sesame oil did not have an open date and there were five prepared bowl containers of dry cereal on a serving tray without a date prepared. During a later interview, the Registered Dietician stated opened food items should be dated and labeled. Facility policy titled "Labeling and Dating of Foods" stated all food items in the storeroom need to be labeled and dated, newly opened food items need an open date and used-by date, and prepared foods need to be covered, labeled, and dated. Another policy titled "Storage of Food and Supplies" stated opened dry food items such as dry cereal should be tightly closed, labeled, and dated.
Missing Care Plan for Risperdal Therapy
Penalty
Summary
The facility failed to ensure a person-centered care plan was developed and implemented for Risperdal ordered for one resident with diagnoses including peripheral autonomic neuropathy, hypotension, paranoid schizophrenia, schizoaffective disorder, and hyperglycemia. The resident was admitted on 5/5/2025, and the medical record also noted fluctuating capacity to understand and make decisions. A physician order dated 5/5/2025 at 9:00 p.m. directed Risperdal 3 mg, one tablet by mouth at bedtime, for paranoid schizophrenia and auditory hallucination to harm others. During a concurrent interview and record review, RN 1 stated there was no documented care plan for Risperdal 2 mg and Risperdal 3 mg ordered for paranoid schizophrenia and auditory hallucination, and stated the care plan was not developed and implemented. RN 1 stated a licensed nurse initiates the care plan and that a comprehensive, patient-centered care plan was required to guide staff in identifying the resident's diagnosis, understanding related needs and behaviors, and implementing individualized interventions. During a later interview and record review, the DON also stated the care plan for Risperdal 2 mg and Risperdal 3 mg was not found and that the absence of a care plan limited nursing staff's ability to recognize changes in condition, provide timely support, and implement appropriate interventions. The facility policy on psychotropic drug treatment stated nursing services, social services, and other IDT members would address behaviors in progress notes and on the resident centered care plan.
Failure to Revise Communication Care Plan
Penalty
Summary
The nursing staff failed to revise Resident 30’s care plan for impaired communication. Resident 30 was admitted to the facility and later readmitted with diagnoses including hearing loss, non-verbal status, and idiopathic peripheral autonomic neuropathy. The admission record also indicated Resident 30 had the capacity to understand and make decisions, and the H&P dated 7/25/2025 stated she had that capacity. The MDS dated 1/7/2026 indicated her cognitive skills were intact, she was independent with ADLs, and she had no impairments of the upper or lower extremities. During a concurrent interview and record review on 1/14/2026, the RN Supervisor stated Resident 30 did not have a care plan regarding communication/language in her medical record. During a later interview and record review with the DON, the DON stated care plans are individualized, updated as needed, quarterly, and upon readmission, and that all active care plans should be in the residents’ chart. The DON also reviewed Resident 30’s Impaired Communication care plan dated 7/22/2025 and stated the target date of 10/2025 should have been updated. The facility policy titled Comprehensive Care Planning stated the care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged.
Failure to Document CPAP Assessment on Admission
Penalty
Summary
The facility failed to document a nursing assessment for the use of CPAP for one of three sampled residents. Resident 78 was admitted on 1/9/2026 with diagnoses including alcohol dependence, nicotine dependence, major depressive disorder, and insomnia. The MDS dated 1/15/2026 indicated the resident had intact cognition and needed supervision for eating, toileting hygiene, dressing, and bathing. During interview, Resident 78 stated he told a licensed nurse on the day of admission that he needed CPAP use and that his mask was missing, and he stated he had used CPAP daily for 2 years for sleep apnea. Record review and staff interviews showed the resident’s belongings list documented a CPAP machine on admission, but the licensed nurses’ notes did not document that the resident reported CPAP use or that an assessment was completed. LVN 3 stated there was no documentation that the resident informed a licensed nurse of the need for CPAP use on admission day. LVN 1 stated RN 1 was made aware of the resident’s history of CPAP use, but there was no documentation that a report was made. RN 1 stated the RN was responsible for the admission assessment and that there was no documentation of an assessment regarding CPAP use. The DON stated there should have been an interdisciplinary team meeting for CPAP use and that a licensed nurse had to document the history of CPAP use; the DON also stated no documentation meant care was not done.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise and monitor a newly admitted resident from a psychiatric facility, resulting in the resident eloping from the facility. The resident, diagnosed with schizophrenia and anxiety disorder, was last seen on the facility's patio during a smoke break. The resident was noted missing after a headcount was conducted, and was found at his family's residence, 22 miles away, over eight hours later. Interviews and record reviews revealed that the resident was last seen on the patio by an Activity Assistant who was the only staff member present with about 20 residents. The assistant lost sight of the resident while attending to other residents. The facility's Director of Nursing and other staff believed that one person was sufficient to monitor the patio, despite the assistant's statement that it was not adequate. The facility's monitoring log showed no designated staff on the patio after 8:30 p.m., and the resident possibly scaled a fence to leave the facility. The facility's policy emphasized the importance of resident safety and supervision, but the actual practice did not align with these guidelines. The facility assessment indicated adequate staffing, but the supervision during the smoke break was insufficient, leading to the resident's elopement. The facility's failure to provide adequate supervision and monitoring directly contributed to the resident's ability to leave the facility unnoticed.
Deficient Food Storage and Thawing Practices
Penalty
Summary
The facility failed to ensure the proper storage, preparation, and distribution of food under sanitary conditions for all 63 residents. During an observation in the dry storage room, two bags of dried pasta were found opened without an open date, which is against the facility's policy requiring newly opened food items to be labeled with an open date. The Dietary Supervisor confirmed the absence of labeling and acknowledged that unlabeled opened food could lead to uncertainty about when the food was opened and when it will expire, potentially compromising the quality of the food. Additionally, the facility did not adhere to its policy for thawing meat. During a kitchen observation, three bags of diced beef were found sitting in a tray of still water, contrary to the facility's policy that requires meat to be thawed under running water at a temperature of 70 degrees Fahrenheit or lower. The staff member responsible for the meat stated that the water was running earlier but was unsure when it was turned off. The meat was then placed in the refrigerator without taking its temperature, which could lead to the risk of food-borne illnesses as stated by the Dietary Supervisor.
Documentation Failures in Medication Administration and Receipt
Penalty
Summary
The facility failed to ensure proper documentation of narcotic administration for one resident, Resident 116, and the receipt of home medications for another resident, Resident 53. For Resident 116, the discrepancy was identified during a review of the Antibiotic or Controlled Drug Record for Lorazepam, which showed that the last dose was administered on a specific date at 7:45 a.m., with 18 tablets expected to remain. However, only 17 tablets were found, indicating a missing dose that was not documented. The Medication Administration Record (MAR) later revealed that the last dose was actually administered at 5:00 p.m. on the same day, but this was not recorded in the narcotic record, leading to a discrepancy in the count. For Resident 53, the issue arose from the lack of documentation when home medications were received by the facility. During an observation, an unopened bag containing unidentified medications was found, and there was no accompanying medication list. This lack of documentation meant that the facility staff were unaware of the specific medications Resident 53 was taking, which is crucial for ensuring proper medication management and continuity of care. The facility's policies and procedures require that controlled medications be documented immediately upon administration and that a physical inventory of all controlled medications be conducted at each shift change. Additionally, medications brought to the facility by residents or family members must be documented upon receipt. The failure to adhere to these policies resulted in potential medication errors and drug diversion risks, as noted by the Director of Nursing.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, which could potentially lead to re-traumatization and negatively impact the resident's psychosocial status. The resident, who was admitted with multiple mental health diagnoses including PTSD, had experienced several traumatic events in the past. Despite this, the facility did not have a trauma-informed care plan in place for the resident. Interviews and record reviews revealed that the resident's care plans lacked documentation of triggers that could cause re-traumatization and did not include personalized interventions to address the resident's PTSD. The Social Services Director confirmed that the resident was assessed for trauma using specific questionnaires, but the care plan and interventions were developed by the nursing staff. However, the Assistant Director of Nursing found no evidence of trauma-informed care plans or trigger-specific interventions in the resident's medical records. The Director of Nursing acknowledged the need for individualized trauma-informed care for residents with PTSD, as outlined in the facility's policy and procedure, which emphasizes culturally competent care to prevent re-traumatization.
Failure to Follow Up on Dental Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received follow-up dental care as recommended by the dentist. The resident, who was admitted with multiple diagnoses including type 2 diabetes, paranoid schizophrenia, generalized anxiety disorder, and depression, required dental crowns on two top front teeth. Despite the resident initially denying treatment and later refusing to be seen on two occasions, there were no further follow-ups or dental notes in the resident's chart after the last refusal. The resident's care plan indicated a need for supervision for oral care and included goals to prevent dental pain, but these were not adequately followed through. Interviews revealed that the resident expressed a desire to have the dental work completed, stating it would improve his self-esteem. The social services director confirmed the lack of follow-up since the resident's last refusal and noted the absence of documentation regarding pending dental crowns. The director of nursing emphasized the importance of tracking ancillary services and following up with residents who initially refuse treatment, as their willingness to receive care may change. The facility's policy indicated dental evaluations should be scheduled annually or as needed, but this was not adhered to in the resident's case.
Failure to Provide Appropriate Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of Resident 33, who was diagnosed with dysphagia and prescribed a pureed diet. During an observation, Certified Nurse Assistant 3 (CNA 3) was seen distributing snacks that included cookies, which are not suitable for a pureed diet. Resident 33 was found with an empty cookie wrapper and another cookie still in its packaging, indicating that they had consumed a cookie that was not in line with their dietary requirements. CNA 3 initially did not know which residents were on pureed diets and later confirmed that Resident 33 was on such a diet, stating that appropriate snacks like yogurt and pudding should be provided. The Speech Language Pathologist (SLP) confirmed that cookies are not appropriate for a resident on a pureed diet. The Director of Nursing (DON) emphasized the importance of following physician orders to prevent risks such as aspiration or choking. The facility's Charge Nurse job description includes implementing nursing interventions as ordered by the physician, which was not adhered to in this instance.
Failure to Document Resident Monitoring
Penalty
Summary
The facility failed to document the visual monitoring of a resident's behaviors every 15 minutes, as required by the resident's care plan. The resident, who was admitted with diagnoses including schizophrenia, depressive episodes, and generalized anxiety disorder, required frequent visual checks to ensure safety and acclimation to the environment. Despite the care plan's intervention to visually check the resident frequently, there was no documentation in the resident's medical records to confirm that these checks were being performed. Observations and interviews with CNAs revealed that they were monitoring the resident closely but were not documenting these actions in the resident's chart. The Assistant Director of Nursing confirmed the lack of documentation, and the Director of Nursing acknowledged that the facility's policy required accurate and detailed clinical records. The facility's policies on documentation emphasized the need for current, accurate, and detailed records, yet the CNAs did not document their monitoring activities as per these guidelines.
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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.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Care Center | 0.6 mi | ★★★★★ | 35 | 0 |
| Villa Serena Healthcare Center | 0.6 mi | ★★★★★ | 16 | 0 |
| Courtyard Care Center | 0.7 mi | ★★★★★ | 28 | 0 |
| Edgewater Skilled Nursing Center | 0.9 mi | ★★★★★ | 21 | 0 |
| Pacific Palms Healthcare | 1.1 mi | ★★★★★ | 41 | 0 |
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