Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Long Beach Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, weakness, and limited mobility required a Hoyer lift and 2-person assist for transfers, and toileting was to be done with a bedpan or bedside commode rather than on the toilet. A RN placed the resident on the toilet and directed staff to transfer the resident back to the wheelchair, and two CNAs manually moved the resident instead of using the ordered lift, resulting in skin tears to the arm and leg. Staff interviews confirmed the resident should not have been toileted in the bathroom and that the transfer was not done as documented in the care plan and Kardex.
A resident receiving palliative care and scheduled morphine for pain had a lapse in the renewal process when a 30-day morphine order expired and the next order was not signed in time for pharmacy dispensing. The resident missed four doses over four days, with no refusals documented, and staff interviews showed the physician, Medical Director, DON, and LPNs all recognized that the order should have been renewed before it ran out.
A resident with dementia, dysphagia, and muscle weakness had a physician order for a chopped texture diet, but was served unchopped quiche and matzoh balls during a meal. The family member reported this happened often and said they had to chop the resident's food themselves, while the DON and DFD confirmed the resident should have received the correct texture and that some items were not chopped before being sent to the unit.
A recertification survey revealed that a five-story building lacked fireproofing on steel structural supports and did not have a fire-rated ceiling assembly, classifying it as a Type II (000) Unprotected, Non-combustible structure. This construction type is not permitted to exceed two stories in height according to the Life Safety Code.
The facility's permanently installed generator was non-functional, as confirmed by the Director of Maintenance. A portable generator was temporarily used to provide emergency power, wired into the building's transfer switch room. The facility was in the process of acquiring a new generator.
The facility did not ensure that HVAC shafts were enclosed with a minimum one-hour fire resistance rating, as required by NFPA standards. Observations during a survey revealed that vertical ventilation ducts on multiple floors lacked proper fire-rated construction and dampers, compromising fire safety compliance.
A recertification survey identified deficiencies in a facility's kitchen operations, including improper dishmachine temperatures, inadequate drying of washed items, and unsanitary storage conditions. Dietary staff were unaware of proper procedures, and the Director of Food Services was not informed of issues, leading to potential contamination risks.
The facility failed to maintain effective infection control, with staff handling medications with bare hands, incorrect isolation signage for a resident with scabies, and unclean medication storage areas. These deficiencies highlight lapses in following infection prevention protocols, potentially risking contamination and transmission of infections.
The facility failed to properly label and store medications on two medication carts, with opened insulin pens and an ophthalmic solution lacking documented open dates. This affected three residents, including one with severe cognitive impairment and another with intact cognition. Staff interviews confirmed the requirement for open dates to ensure timely disposal, as per facility policy.
A facility failed to implement a Pharmacist's recommendations for a resident's insulin management. The attending Physician initially agreed to the recommendations but later decided not to implement them due to clinical reasons, without documenting the rationale. This led to a deficiency as the facility's policy requires such recommendations to be acted upon and documented.
The facility did not submit a CHRC 105 Form within the required 30-day period after receiving a negative determination for a prospective employee. The oversight occurred because the employee was not hired and thus not in the payroll system, leading to a delay in termination from the CHRC system.
Two residents with pressure ulcers did not receive necessary treatment due to improper air mattress settings. One resident's mattress was set to an incorrect weight, while another's mattress was unplugged, rendering it non-functional. Nursing staff, including the Wound Care RN and DON, acknowledged the oversight and emphasized the importance of correct settings and functionality.
A resident received the wrong enteral formula due to a lack of labeling and failure to update the feeding solution as per the physician's order. The nursing staff did not label the feeding bottle with the necessary details, and there was a lack of awareness about the change in the feeding solution order, despite being aware of the change in flow rate.
Failure to Follow Transfer Assistance and Toileting Care Plan
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent an accident during toileting and transfer care. The resident had diagnoses including dementia, difficulty walking, and muscle weakness, and was dependent on staff for toileting hygiene and toileting transfers. The resident’s care plan and Kardex documented that a Hoyer mechanical lift and two-person assistance were required for chair/bed-to-chair transfers, and that toilet transfer was not to be attempted due to medical condition or safety concerns; toileting needs were to be met with a bedpan or bedside commode. On the evening of the incident, a registered nurse placed the resident on the toilet and then instructed a CNA to transfer the resident back to the wheelchair. Two CNAs manually transferred the resident from the toilet to the wheelchair instead of using the documented mechanical lift and required assistance. During that transfer, the resident sustained skin tears to the left arm and left leg. The accident and incident report documented the injury, and written statements from staff confirmed that the resident was manually transferred from the toilet to the wheelchair. Interviews and record review showed that staff were aware the resident should not have been toileted in the bathroom. A CNA stated the resident should not have been placed on the toilet, another CNA stated they had to support the resident’s weight while balancing and lowering the resident to the wheelchair, and the unit nurse stated the resident should have been provided a bedpan for toileting needs and was not supposed to be placed on the toilet for safety reasons. The DON stated staff must check the resident’s Kardex and care plans for the level of assistance and devices needed and stated the incident was avoidable.
Missed Morphine Doses Due to Unrenewed Physician Order
Penalty
Summary
The facility failed to ensure that a resident’s medical care was supervised by a physician and that orders for immediate care and needs were maintained throughout the resident’s stay. The deficiency involved one resident who was admitted with Alzheimer’s disease, a stage 4 sacral pressure ulcer, and a closed fracture of the left femur, and who was receiving palliative care and scheduled opioid medication for pain management. The resident’s records showed ongoing physician orders for morphine sulfate oral solution, ordered in 30-day intervals for bedtime pain control. A morphine order that ended was re-ordered for another 30 days, but the prescription was not signed by the physician, so the pharmacy could not dispense it. As a result, the resident did not receive morphine for four days, with four doses missed, and there were no refusals documented in the record. The medication was later re-ordered after the resident’s family complained about the missed doses. Interviews showed that staff and providers were aware of the lapse in the renewal process. The physician stated nursing should have notified the physician when the order expired, and the Medical Director stated the lapses should not have happened and that nurses needed to call the physician when medication was running out. The DON stated nurses should initiate re-ordering early enough to avoid delays in obtaining the physician signature, and the pharmacist stated there was no explanation from the pharmacy side for why the order was not re-ordered until after expiration.
Resident on chopped diet received unchopped meal items
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered chopped texture diet received food prepared in the correct form. The resident had diagnoses including dementia, dysphagia, and muscle weakness, and care plan interventions called for diet and food consistency per physician order, along with assistance and monitoring during meals. The physician order required no concentrated sweets, chopped texture, and thin liquids, and a speech language pathologist note documented that the resident continued to tolerate a chopped diet with thin liquids. On the dinner meal in question, the resident was served a slice of quiche and matzoh balls in soup that were not chopped, despite the chopped diet order. The resident's family member stated they often had to chop the resident's food themselves and reported that the unchopped meal was shown to an LPN. The Director of Food Services confirmed the resident was on a chopped texture diet and received unchopped quiche and matzoh balls, and stated these items were not chopped before delivery to the unit because kitchen staff did not chop certain foods to preserve their structure and presentation. The DON stated nursing staff must ensure residents on mechanically altered diets received the appropriate textured food, and the LPN stated they would chop food upon request but could not recall whether they assisted with this meal.
Fire Safety Deficiency in Building Construction
Penalty
Summary
During a recertification survey, it was observed that a five-story building did not meet the fire safety requirements as per the NFPA 101 Life Safety Code. Specifically, the steel structural supports above the suspended ceiling on floors 1-4 were not provided with fireproofing material. Additionally, there was no documentation to confirm that the inlay drop ceiling was a fire-rated listed assembly. These observations were made during the life code survey conducted over two days. The lack of fireproofing on the steel structural members and the absence of a fire resistance-rated ceiling assembly led to the classification of the building as a Type II (000) Unprotected, Non-combustible structure. According to the Life Safety Code, buildings of this construction type are prohibited from being more than two stories in height. The findings were communicated to the facility's Administrator, Corporate Director of Maintenance, and Director of Maintenance during the Life Safety Code exit conference.
Deficiency in Emergency Power System
Penalty
Summary
The facility was found to have a deficiency related to its emergency power system during a recertification survey. It was observed that the permanently installed generator set within the building was non-functional. This was confirmed through an interview with the Director of Maintenance, who stated that the in-house generator had stopped working and was not repairable. As a temporary measure, a portable generator was being used to provide emergency power, which was wired into the transfer switch room of the building. The facility was in the process of procuring and installing a new permanently installed generator.
Failure to Ensure Fire-Resistant HVAC Shafts
Penalty
Summary
The facility failed to ensure that the heating and ventilating shafts were enclosed with a minimum fire resistance rating of at least one hour, as required by the 2012 NFPA 101 and NFPA 90A standards. During the recertification survey, it was observed that the HVAC ductwork serving residents' toilet rooms and soiled utility rooms did not meet the necessary fire resistance requirements. Specifically, vertical ventilation ducts passing through floors on the 2nd, 3rd, and 4th floors were not enclosed with one-hour fire-rated construction within the interstitial spaces above the suspended ceilings. Additionally, there were no fire-rated dampers installed at the floor level where the ducts penetrated the floor. These deficiencies were identified during a life code survey conducted over two days, and the findings were communicated to the facility's Administrator, Corporate Director of Maintenance, and Director of Maintenance during the Life Safety Code exit conference. The lack of proper fire resistance measures in the HVAC system represents a failure to comply with the specified fire safety standards, potentially compromising the safety of the facility's environment.
Sanitation and Storage Deficiencies in Kitchen Operations
Penalty
Summary
The facility was found to have deficiencies in its sanitation practices during a recertification survey. The high-temperature dishmachine was observed to have a final rinse temperature below the required 180 degrees Fahrenheit, with readings of 122 and 121 degrees Fahrenheit. Dietary staff, including Dietary Aide #1 and Dietary Aide #2, were not aware of the proper procedures for operating the dishmachine or monitoring the chemical sanitization process. The Director of Food Services was not informed of the low temperatures, which should have prompted immediate action to address the issue. Additionally, the facility failed to ensure that washed cooking equipment and trays were properly dried before storage. Observations revealed that wet trays, plates, and domes were being stacked and stored without adequate air-drying, leading to potential contamination. The Director of Food Services acknowledged the lack of sufficient space and drying racks to allow for complete air-drying of items before storage. The facility also had issues with cleanliness and storage in the kitchen and storage areas. One of the air circulation fans in the walk-in refrigerator was dusty with black build-up, and the dry goods storage room floor was unclean. Non-food items were improperly stored directly on the floor in the paper goods storage room. The Director of Food Services confirmed that these practices were against the facility's policies, which require a clean environment and proper storage of items.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 I. Immediate Corrective Action While no residents were identified as being harmed by the deficient practices, immediate corrective actions were taken to address observed sanitation and food safety issues: - The dish machine was taken out of service immediately. Dishes were sanitized using the approved 3-compartment sink method with chemical sanitizer until the dish machine was repaired and recalibrated. - All wet dishes and utensils that had been improperly stored were rewashed, properly air-dried, and stored in a sanitary manner. - The dirty air circulation fan in the walk-in refrigerator was cleaned and sanitized. - The dry goods storage room was cleaned, with all debris and spilled food removed. - The dirty condiment tray was discarded. - All items improperly stored on the floor in the paper goods storage area were relocated to appropriate shelving. - Staff involved were counseled and re-educated on proper food safety protocols and dish sanitization procedures. II. Identification of other residents Although no direct resident harm was identified, all residents who receive food prepared in the facility could have been affected by the improper sanitization of dishware and unsanitary kitchen conditions. - All noncompliant practices were corrected on the spot. III. Systemic Changes - The facility policies titled Dish Machine Procedure and Storeroom/Food Delivery Procedures were reviewed and found to be in compliance with the regulations. - Staff were re-educated on dish machine operation, temperature requirements, and procedures for chemical sanitization. - The kitchen staff were re-educated on dishware and food storage and maintaining the cleanliness of the kitchen overall. - All dietary staff were in-serviced on how to read temperature gauges and test chemical concentrations when needed. - A No Wet Nesting policy was reinforced, and staff are now required to inspect items for dryness prior to storage. All dietary staff were educated on the No Wet Nesting policy. - A weekly cleaning schedule was developed and assigned to staff for: - Walk-in refrigerator cleaning (including fan guards). - Dry goods and paper goods storage areas. - Removal of expired, open, or improperly stored items. - Nothing on the Floor signage was placed in all storage areas. IV. QA Monitoring - An Audit Tool has been developed to track compliance with the facility policies titled Dish Machine Procedure and Storeroom/Food Delivery Procedures such as: - Documentation of daily dish machine temperature checks. - Weekly sanitation inspections of all food preparation and storage areas. - Monitoring of dish storage for signs of wet nesting or improperly dried items. - This audit will be conducted by the Food Service Director/Designee weekly for three months. - Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Food Service Director
Infection Control Deficiencies in Medication Handling and Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a recertification survey. During a medication administration observation, an LPN handled medications with bare hands for a resident, which is a breach of infection control protocols. The LPN acknowledged the error but did not initially discard the contaminated medications. Additionally, another LPN failed to sanitize their hands after picking up an electrical cord from the floor before preparing medications for a resident, and an RN did not sanitize their hands before applying wound medication to a resident with pressure ulcers. The facility also failed to implement correct isolation precautions for a resident diagnosed with scabies. Incorrect signage was posted outside the resident's room, leading to confusion among staff about the necessary precautions. The Director of Nursing Services, responsible for posting the signage, admitted the error, and staff interviews revealed a lack of understanding of the differences between Enhanced Barrier Precautions and contact isolation precautions. This miscommunication could have led to inadequate protection for staff and visitors entering the resident's room. Furthermore, the facility did not maintain cleanliness in the medication storage areas. An observation revealed that the medication refrigerator in one unit had dirty drug labels and debris, which the nursing staff failed to address. The Director of Nursing Services confirmed that the nursing staff was responsible for ensuring the cleanliness of the medication refrigerator, and the presence of debris could pose an infection control risk due to potential contamination of stored medications.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action - Resident #32: Medications dispensed by hand were discarded immediately upon identification, and a new, properly handled dose was administered. Licensed Practical Nurse #1 received immediate re-education on infection control standards during medication administration. - Resident #133: The Enhanced Barrier Precautions (EBP) signage was removed and replaced with the correct Contact Isolation signage per physician order [REDACTED]. - Resident #50: Registered Nurse #3 was re-instructed on proper hand hygiene protocols. Resident’s wound site was reassessed with [REDACTED]. No harm identified. - Unit 4 Medication Refrigerator: The medication refrigerator was immediately cleaned and disinfected. All outdated or damaged labels were removed, and the area was sanitized according to facility policy. RN Supervisor was counseled on proper oversight. - Resident #3: Licensed Practical Nurse #2 sanitized their hands after being prompted by the surveyor. Nurse was immediately reminded of hand hygiene protocol prior to medication handling. II. Identification of other residents - Any resident receiving wound care and/or medication has the potential to be affected by this deficiency. - All residents on any level of Infection Control Precautions were assessed for the correct signage on their room door. - All signage matched the physicians’ orders. - All medication storage room refrigerators were assessed and found to be clean. III. Systemic Changes - The facility policies titled Medication Administration Guidelines, Pressure Injury/Pressure Ulcer Assessment, Prevention and Management, Infection Prevention Control Program, Contact Precautions, Enhanced Barrier Precautions and Medication Refrigerator Cleaning were reviewed and found to be in compliance with the regulations. - All licensed nurses will be educated on proper infection prevention policies and practices during medication administration and wound treatment, as well as medication storage room refrigerator cleaning procedures. - The Infection Preventionist will be educated on utilizing precaution signage according to physician’s orders. - A copy of the attendance sheet will be filed for reference and validation. IV. QA Monitoring - Existing medication pass and wound treatment competencies will be used to audit infection prevention/control practices during these service provisions. Each licensed nurse will be assessed monthly for three months. - An Audit Tool has been developed to monitor the placement of appropriate infection precaution signage on resident room doors. An Audit Tool has been developed to assess the cleanliness of medication storage room refrigerators. - Five licensed nurses will be audited weekly for one month using the two audits (Medication Pass and Wound Treatment Competencies). Further audits will be conducted on 5 nurses monthly for 2 months. - The placement of appropriate infection precaution signage on resident room door will be audited weekly for one month, then monthly for 2 months. - The cleanliness of medication storage room refrigerator will be audited weekly for one month, then monthly for 2 months. - Audit findings will be compiled, analyzed and brought to the QAPI Committee. - During the quarterly QAPI Committee meeting, the audit results will be reviewed and assessed for continuance, based on compliance and incidence of negative findings. Responsible Party: Director of Nursing
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on two of the three medication carts reviewed during the survey. Specifically, an opened insulin pen and an ophthalmic solution bottle were found without documented open dates on the Unit 4 West medication cart. The facility's policy requires that multi-dose vials be dated upon opening and discarded within 28 days unless otherwise specified by the manufacturer. Resident #92, who had intact cognition, was receiving insulin injections, and Resident #98, who had severe cognitive impairment and impaired vision, was using the ophthalmic solution. The lack of open dates on these medications meant that staff could not determine when they should be discarded, potentially affecting their efficacy and safety. Additionally, on the Unit 2 East medication cart, an opened Humalog insulin pen for Resident #436 was also found without an open date. This resident had intact cognition and was taking hypoglycemic medication. Interviews with nursing staff and the pharmacist confirmed that insulin pens should be discarded 28 days after opening, and all open medications should have the open date documented. The Director of Nursing Services reiterated that nurses are responsible for ensuring proper labeling and storage of medications, and discontinued medications should be removed from the medication cart.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action - Resident #92: The opened [MEDICATION NAME] pen was immediately removed and replaced with a properly labeled pen reflecting the current date of opening. Medication administration was not interrupted, and the resident was not harmed. - Resident #98: The discontinued [MEDICATION NAME] Ophthalmic Solution was immediately discarded upon identification. Resident’s active medications were reviewed to ensure no expired or discontinued medications remained on hand. - Resident #436: The improperly labeled Humalog insulin pen was discarded, and a new insulin pen with a documented open date was initiated per physician order. Resident continued to receive timely insulin administration without clinical consequence. II. Identification of other residents - A facility-wide audit of all medication carts and medication storage areas was conducted on 3/21/2025 by the Director of Nursing (DON) and Unit Nurse Managers. - The audit focused on: All multi-dose vials, insulin pens, and ophthalmic solutions in use. Verification that each item was appropriately labeled with the date opened. Removal if any expired or discontinued medications are observed. - There were no negative findings from this review. III. Systemic Changes - The facility policy titled Storage of Medications was reviewed and found to be in compliance with the regulations. - All licensed nurses will be re-educated on the proper handling of open and/or expired medications including: All medications that require discarding within a specific time frame or shortened expiration dates once opened (e.g., 28 days after opening) must be labeled with the date opened upon first use. All discontinued medications must be removed from the cart or storage area immediately. A medication must not be used unless it is properly labeled. - A copy of the attendance sheet will be kept on file for validation. - The Pharmacy Consultant will reinforce labeling and storage requirements in monthly audits and report deficiencies in real time to the DON. IV. QA Monitoring - The RN Supervisor will conduct weekly medication cart and medication refrigerator audits for 4 weeks, verifying: - All opened medications have a clear, legible open date. - No expired or discontinued medications are present. - After 4 weeks of 100% compliance, audits will continue monthly for 3 months, then be reviewed for integration into routine quarterly pharmacy audits. - Results will be reported to the QAPI Committee monthly. Any trends in noncompliance will prompt immediate re-education and performance improvement plans. Responsible Party: Director of Nursing
Failure to Implement Pharmacist's Recommendations for Insulin Management
Penalty
Summary
The facility failed to ensure that irregularities reported by the Pharmacist were acted upon for a resident reviewed for unnecessary medications. Specifically, the attending Physician agreed to the Pharmacist's recommendations to evaluate sliding scale insulin coverage and decrease finger sticks for blood glucose readings for a resident, but these recommendations were not implemented. The facility's policy requires that recommendations from the Pharmacist be acted upon and documented, but this was not done in this case. The resident involved had severe cognitive impairment and was receiving insulin injections. The Pharmacist recommended discontinuing sliding scale insulin and reducing fingerstick orders, which the attending Physician initially agreed to. However, the Physician later decided not to implement these changes due to clinical reasons, including the resident's history of episodes of high and low blood sugar, recent start of an oral diabetic medication, and recent removal of enteral tube feeding. The Physician did not document their rationale for not implementing the recommendations in the resident's medical record. Interviews with facility staff revealed that the nursing supervisors were responsible for reviewing the Medication Regimen Review forms and contacting the attending Physician, but they could not recall reviewing the recommendations for the resident. The Medical Director and Director of Nursing Services stated that the attending Physician should have documented their rationale for not implementing the Pharmacist's recommendations. This lack of documentation and action led to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action The attending physician has reviewed the pharmacist’s Medication Regimen Review (MRR) recommendations dated 1/6/2025 and 2/5/2025 and provided retrospective clinical rationale for not implementing certain recommendations. II. Identification of other residents A facility-wide audit of all residents with pharmacist Medication Regimen Reviews completed within the past 90 days was initiated and completed on 3/30/2025. No negative findings resulted from this review. III. Systemic Changes The facility policy titled Medication Regimen Reviews was reviewed and found to be in compliance with the regulations. All providers will be educated on the requirement to follow through on agreed to pharmacist recommendations documented in the monthly Medication Regimen Review. The Director of Nursing (DON) or designee will verify that pharmacist recommendations are routed to the attending physician and that responses are tracked through a MRR Response Tracking Log. Attending physicians were provided written notification and guidelines reminding them of the regulatory requirement to act on pharmacist recommendations and document rationale if no change is made. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled Medication Regimen Reviews. Audits will be conducted monthly by the Medical Director for three months. The audit includes: Verification that the attending physician reviewed and responded to each pharmacist recommendation. Confirmation that any agreed-upon recommendations were implemented and documented in the resident’s medical record. Identification of any discrepancies or lack of documentation of physician rationale. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Medical Director
Failure to Timely Submit CHRC 105 Form for Non-Hired Employee
Penalty
Summary
The facility failed to submit a Criminal History Record Check (CHRC) 105 Form within the required 30-day time frame to the New York State Department of Health (NYSDOH) after receiving a negative determination letter for a prospective employee, identified as Employee #6. The facility received a Final Denial-b Letter from the NYSDOH on January 14, 2025, indicating that Employee #6 was not eligible for hire. However, the facility did not submit the necessary 105 Form to terminate Employee #6 from the CHRC system until February 14, 2025, which exceeded the 30-day requirement. The Human Resources Coordinator explained that the oversight occurred because Employee #6 was never hired and thus was not included in the facility's payroll system, which is used to generate weekly termination reports. This led to Employee #6 being overlooked in the termination process. The Administrator acknowledged that the Human Resources Coordinator should have submitted the 105 Form within the 30-day period following the receipt of the Final Denial-b Letter, as Employee #6 was never intended to be hired.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action For Employee #6, who received a Final Denial-B letter on 1/14/2025, the facility submitted the required CHRC 105 Form on 2/14/2025. Although delayed, the employee had no contact with residents, was not entered into the payroll system, and was never employed by the facility. The potential employee affected by the deficient practice had his Form 105E processed prior to the beginning of the recertification survey. The employee record has been updated to reflect the final CHRC action and the associated submission date to NYSDOH. The Human Resources Coordinator was counseled and received additional education regarding CHRC reporting timelines and the proper handling of applicants who are denied clearance but never hired. II. Identification of other employees CHRC records were reviewed and there were no other outstanding Final Denial Letters found. III. Systemic Changes The facility policy titled State Mandated Criminal History Record Check was reviewed and found to be in compliance with the regulations. The two facility Authorized Persons have been educated as to the requirement to take the necessary action when in receipt of a Final Denial Letter, within 30 days of receipt of the letter. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled State Mandated Criminal History Check. This audit will be conducted by either of the Authorized Persons every other week. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Administrator
Failure to Ensure Proper Air Mattress Functionality for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for two residents. The first resident, who was admitted with a pressure ulcer and had a high risk for developing additional ulcers, was found to have an air mattress weight setting that did not correspond with their actual weight. This discrepancy was observed during a survey, and the Wound Care Registered Nurse acknowledged the mistake, stating that the correct weight setting is crucial for wound healing. The Director of Nursing Services confirmed that it is the responsibility of the nursing staff to ensure the air mattress settings are correct. The second resident, who was at risk for pressure ulcer development and acquired an unstageable pressure ulcer while in the facility, was found lying on an air mattress that was not plugged into a power outlet, rendering it non-functional. This was discovered during an observation, and the issue was rectified by plugging the mattress into the outlet. The Wound Care Registered Nurse and the Director of Nursing Services both stated that all nursing staff, including Certified Nursing Assistants, are responsible for ensuring that the air mattress is plugged in and functioning properly.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action Despite routine checks of functionality and of the adjustment knob by nursing staff, the air mattress setting was inadvertently not aligned with the resident’s current weight. Resident #123: The air mattress was immediately adjusted to match the resident’s actual weight of 95.6 lbs. Resident #50: The air mattress was immediately plugged into the power outlet and confirmed to be fully functional. Staff involved were re-inserviced on their responsibilities regarding equipment operation. Care plan and treatment orders were reviewed and reinforced. II. Identification of other residents A facility-wide audit of all residents with physician orders [REDACTED]. The audit included verification of: - Current weight settings vs. resident weight. - Functionality (power connection) of each air mattress. - Staff awareness regarding equipment monitoring. III. Systemic Changes A mandatory in-service training will be conducted for all licensed nurses and CNAs on: - Importance of matching air mattress settings to resident weight. - Daily functionality checks (including ensuring the mattress is plugged in and operating properly). - Documentation and escalation protocols if discrepancies are noted. The policy on Air Mattress was reviewed and found to be appropriate. A modification has been made whereby an Air Mattress Check q shift has been added to the Treatment Accountability Record (TAR), requiring a nurse signature. IV. QA Monitoring An audit tool was developed for all residents on air mattresses for: - Correct weight settings - Proper power/functionality - Accuracy of related documentation Audit results will be submitted to the Director of Nursing weekly. Any non-compliance identified will be addressed with immediate re-education and progressive disciplinary action if warranted. Audit frequency will be weekly for 1 month, monthly for 2 months until 100% compliance. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Person Responsible: Wound Care Coordinator
Failure to Administer Correct Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the correct treatment and services to prevent complications. Specifically, a resident was administered the wrong enteral formula, Glucerna 1.5, instead of the prescribed Glucerna 1.2. The bottle containing the enteral formula lacked a label with the resident's name, flow rate, and the time and date of administration, which is against the facility's policy. This oversight was observed during a survey, where it was noted that the feeding had been started the previous day and was leaking at the time of observation. The resident in question had a history of significant weight loss and was on a feeding tube, with a physician's order to change the formula to provide additional calories and protein. However, the nursing staff failed to update the feeding solution as per the new order. Interviews with the nursing staff revealed a lack of awareness regarding the change in the feeding solution order, although they were aware of the change in flow rate. The Director of Nursing Services confirmed that the tube feeding bottle should have been labeled correctly, and the nurses were expected to verify the physician's orders before administration.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action The incorrect tube feeding formula (Glucerna 1.5) on Resident #123 was identified. The correct formula (Glucerna 1.2) as per the physician's updated order dated 3/13/2025 was initiated. The licensed nurse responsible for the deficient practice was identified and received disciplinary action. The resident's weight, tolerance to feeding, and nutritional intake were reassessed by the interdisciplinary team, including the Registered Dietitian and primary care provider. II. Identification of other residents A comprehensive audit was initiated and completed for all residents receiving enteral nutrition to: - Verify that the formula being administered matches the most current physician order. - Ensure that all enteral feeding containers are clearly labeled with resident identifiers, prescribed formula, flow rate, and time of administration. No negative findings were identified from this review. III. Systemic Changes The Enteral Nutrition Administration policy was reviewed and revised to reinforce: - The requirement that nurses must verify both the formula and flow rate against the physician’s most current order before administering or hanging tube feedings. - Mandatory labeling of every tube feeding bottle with the resident’s name, formula, flow rate, and time started. Mandatory in-service training will be conducted for all licensed nursing staff, focusing on: - Interdisciplinary communication related to order changes (e.g., from dietary to nursing). - Proper verification of tube feeding orders and documentation procedures. - Risks of administering incorrect formulas (e.g., weight loss, aspiration, metabolic imbalance). Nursing shift-to-shift handoff documentation was revised to include a checklist for enteral nutrition administration, including verification of the formula, rate, and labeling compliance. IV. QA Monitoring A Tube Feeding Audit Tool has been developed and will be utilized by the RN Supervisor or Designee as follows: - Weekly audits for four weeks to verify accurate formula administration, proper labeling, and correct documentation. - Thereafter, audits will be conducted monthly for three months or until sustained compliance is achieved. Audit results will be reported to the Director of Nursing. Staff found non-compliant will receive immediate re-education and may be subject to progressive disciplinary measures as needed. The Director of Nursing will continue to oversee adherence to the enteral nutrition protocols as part of ongoing performance improvement. Audit findings will be presented to the QAPI Committee during the quarterly meeting for review and determination of whether to continue with the audits. Responsible Party: Director of Nursing
What surveyors are citing around you — mapped
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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 950 citations issued within 25 miles in the last 12 months — including the 17 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 Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand Rehabilitation And Nursing At South Poin | 0.5 mi | ★★★★★ | 0 | 0 |
| Park Avenue Extended Care Facility | 0.8 mi | ★★★★★ | 0 | 0 |
| Beach Terrace Care Center | 1.7 mi | ★★★★★ | 13 | 0 |
| Grandell Rehabilitation And Nu | 1.7 mi | ★★★★★ | 0 | 0 |
| Oceanside Care Center Inc | 3.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.