Long Beach Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #10) of three residents reviewed for Accident. Specifically, Resident #10 required a Hoyer (mechanical) lift and two persons assistance for chair/bed-to-chair transfer and a toilet transfer was not attempted due to medical condition or safety concerns as per the resident's plan of care. On 05/15/2026 Registered Nurse #9 placed Resident #10 on the toilet and then instructed Certified Nursing Assistant #9 to transfer Resident #10 back to their wheelchair. Certified Nursing Assistant #9 and Certified Nursing Assistant #6 manually transferred Resident #10 back to the wheelchair resulting in skin tears on the resident's left arm and left leg.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the medical care of each resident was supervised by a physician and that orders for each resident's immediate care and needs were provided throughout the resident's stay. This was identified for one (Resident #2) of two residents reviewed for Quality of Care/Treatment-Drugs and Medication. Specifically, Resident #2 had ongoing physician orders for Morphine Sulfate Oral Solution (a narcotic drug used for pain control), ordered for a 30-day interval each time. A 30-day order that ended [DATE] was re-ordered on [DATE] for another 30 days, but the prescription was not signed by the physician and therefore, the medication could not be delivered by the pharmacy and the resident did not receive the morphine for four days ([DATE]-[DATE] (four doses were missed); [...]

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs. This was identified for one (Resident #10) of three residents reviewed for Nutrition. Specifically, on 07/06/2026, Resident #10 was not served chopped textured consistency diet as ordered by the physician.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. This was identified for two (Unit 2 East and Unit 4 [NAME] medication carts) of three medication carts reviewed during the Medication Storage Task. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, 1) during the kitchen observation on 3/17/2025, the final rinse temperature of the high-temperature dishmachine was observed to be below 180 degrees Fahrenheit. [...]

Inspectors wrote3) The facility's policy titled Medication Refrigerator Cleaning dated 11/2017 documented all medication refrigerators will be cleaned. The night shift licensed nurse assigned to clean the refrigerator at least once a week using a wet cloth or paper towel to clean the interior and exterior cabinet with warm water and wipe the inside of the refrigerator with disinfectant wipes and leave to dry, following the air-dry time of the disinfectant wipes. During an observation on 3/20/2025 at 1:44 PM, the Unit 4 medication storage room refrigerator was observed with dirty drug labels adhered/stuck on the refrigerator shelf and there was dry, scattered debris at the bottom of the refrigerator. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/17/2025, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for two (Resident #123 and Resident #50) of three residents reviewed for Pressure Ulcers. Specifically, 1) Resident #123 had a physician's order to use an air mattress due to an unstageable pressure injury (a full-thickness tissue loss in which the depth of the wound bed is obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) to the right elbow. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that a resident with a limited range of motion receives appropriate treatment and services. This was identified for one (Resident #42) of seven residents reviewed for Activities of Daily Living. Specifically, Resident #42 was observed on multiple occasions with a gauze roll in their left hand. The resident's Comprehensive Care Plan documented the discontinuation of the use of the gauze roll in April 2024. An interview with the Director of Rehabilitation revealed that any object in the resident's hands may stimulate involuntary tone and greater tension in the resident's hands which was more detrimental than beneficial for the resident due to the Traumatic Brain Injury diagnosis. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that each resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding (tube feeding). This was identified for one (Resident #123) of one resident reviewed for Tube Feeding. Specifically, on 3/17/2025, Resident #123 received the wrong enteral formula. The bottle for the enteral formula did not have a label indicating the resident's name, the flow rate, the time, and the date of the administration. The finding is: The facility's policy titled Administration of Gastrostomy Tube Feeding, effective 3/2025, documented tube feeding shall be administered and monitored by a licensed nurse upon the written order of a Physician/Nurse Practitioner. [...]

Inspectors wroteBased on interviews and record review during the Recertification Survey and Abbreviated Survey (NY 00357077) initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one (Unit 3) of three resident units review for Sufficient and Competent Nurse Staffing. Specifically, there were insufficient Certified Nursing Assistants staffed on Unit 3 on the weekends for the following dates: 9/21/2024, 9/22/2024, 9/28/2024, 9/29/2024, and 10/6/2024 for various shifts. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that irregularities reported by the Pharmacist to the attending Physician, the facility's Medical Director, and the Director of Nursing were acted upon for each resident. This was identified for one (Resident #59) of five residents reviewed for Unnecessary Medications. Specifically, the attending Physician for Resident #59 agreed to the recommendations to consider evaluating sliding scale insulin coverage and decreasing finger sticks to twice a day to obtain blood glucose readings made by the Pharmacist; however, the recommendations were not implemented. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025 the facility did not ensure that nurse staff posting data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, The facility entrance lobby was observed on 3/17/2025 at 9:00 AM with the Daily Staff Posting dated 3/13/2025. There were no Daily Staff Postings for 3/14/2025, 3/15/2025, 3/16/2025 and 3/17/2025. Additionally, the Daily Staff Posting did not include the actual number of licensed and unlicensed nursing staff per shift. The finding is: During an observation on 3/17/2025 at 9:00 AM, a Daily Staff Posting dated 3/13/2025 was observed near the facility reception area. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 9/7/2023 and completed on 9/13/2023, the facility did not ensure that the resident's Primary Care Physician (PCP) comprehensively reviewed the resident's total program of care. This was identified for one (Resident #51) of five residents reviewed for Unnecessary Medications. Specifically, Resident #51 was started on Digoxin (a medication used to treat various heart conditions) on 4/16/2023. On 5/12/2023, the consultant Pharmacist recommended to obtain the serum (blood) Digoxin level. The PCP agreed with the recommendations; however, the serum Digoxin level was not obtained until 6/16/2023 and resulted in a critically high serum Digoxin level. On 6/19/2023 Resident #51's PCP reviewed the laboratory workup and then discontinued the Digoxin medication. The finding is: [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 9/7/2023 and completed on 9/13/2023, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This was identified for one (Resident #68) of two residents reviewed for pressure ulcers. Specifically, Resident #68 had a care plan intervention to offload heels while in bed with pillows; however, the resident was observed in bed on multiple occasions with their heels not offloaded but resting on the mattress. When this was brought to the attention of a Certified Nursing Assistant (CNA), the CNA repositioned a pillow directly under the heels, not allowing the heels to be offloaded. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 9/7/2023 and completed on 9/13/2023, the facility did not ensure that their policy regarding the Pharmacy Medication Regimen Review (MRR) included time frames for the different steps in the process when the pharmacist identifies an irregularity. Specifically, the facility's policy on Drug Regimen Review did not include timeframes of when the Physician should review the recommendations made by the Pharmacist and document their response. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 9/7/2023 and completed on 9/13/2023 the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #10) of six residents observed during medication administration. Specifically, during the medication administration observation for Resident #10 on 9/8/2023, Registered Nurse (RN) #3 donned (put on) gloves and handled medication tablets with the gloved hands. RN #3's gloved hands came in contact with the medication cart drawers, medication blister packs, and medication bottles during the process. The finding is: [...]

Inspectors wroteBased on observation and staff interviews during the Recertification Survey completed on 7/13/2021 the facility did not ensure that food service equipments were clean. Specifically, the cooking range hood panels were observed to be soiled with heavy grime, grease, soot and debris build up. The finding is: During the initial kitchen tour on 7/6/2021 at 9:15 AM with the Food Service Director (FSD) present the entire cooking range exhaust hood (approximately 20 feet long) was observed with heavy grime, grease, soot and debris build up. The FSD stated on 7/6/2021 at 9:15 AM that they (the FSD) started as a FSD a month ago and noticed that the hood required cleaning. The FSD stated that the hood was last serviced by a cleaning company in January 2021. He stated that he contacted the cleaning company 2 weeks ago and was given an appointment for today evening. [...]

Inspectors wroteBased on observations, resident and staff interviews and record review during a Recertification survey, the Facility did not ensure that all mechanical, electrical, and patient care equipment were maintained in safe operating condition. This was identified for two of two Mechanical lifts (Sarita lifts) that were utilized to transfer residents from one surface to another. Specifically, the safety straps for positioning the residents' legs on both Sarita lifts were in disrepair. The finding is: Resident #45 was admitted with Diagnosis including Multiple Sclerosis, Muscle Spasms, Generalized Muscle Weakness and Neuro Muscular Dysfunction of bladder. The Physician's order dated 5/10/2021 included to transfer the resident with a Sarita Lift with two persons assistance to a standard or motorized wheelchair. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (complaint #NY 00273922) completed on 7/13/2021 the facility did not ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. This was noted for one (Resident #45) resident reviewed for choices in a sample of 26 residents. Specifically, Resident #45 requested to be placed back to bed between 4:30 and 5:30 PM. The facility staff did not honor the resident's request consistently. The finding is: Resident #45 was admitted with diagnoses including Multiple Sclerosis, Neuromuscular Dysfunction of the bladder and Generalized Muscle weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00272845) completed on 7/13/2021 the facility did not ensure that each resident's physician was notified in a timely manner when there were clinical complications and a need to alter treatment for 1 (Resident #317) of 2 residents reviewed for hospitalization. Specifically, Resident #317 had an unstageable pressure ulcer to the sacrum and was identified to be newly malodorous by a Registered Nurse (RN) on 1/31/2021; however, the wound condition was not reported to the physician until 2/2/2021. The finding is: Resident #317 was admitted with diagnoses including Displaced Intertrochanteric Fracture Left Femur, Schizophrenia, and Muscle Weakness. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey completed on 7/13/2021, the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed that included measurable objectives and interventions to meet the resident's medical and nursing needs to attain or maintain the resident's highest practicable well-being. This was identified for 1 (Resident # 53) of 1 resident reviewed for behavior and mood. Specifically, Resident #53 exhibited hoarding behavior and there was no CCP developed with goals and interventions to address this behavior. The finding is: Resident #53 was admitted with diagnoses including Antisocial Personality Disorder, Mood Disorder, and Major Depressive Disorder. [...]

Inspectors wroteBased on Observation, record review and interviews during the Recertification Survey completed on 7/13/2021, the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's current care needs. This was identified for one (Resident #45) of 4 residents reviewed for Activities of Daily Living (ADLs) and one (Resident #317) of three residents reviewed for Pressure Ulcers. Specifically, 1) Resident #45 requested to be placed back to bed before supper and the facility did not review and revise the CCP to include the resident's preference. 2) Resident #317 with Pressure Ulcers had a CCP for use of Bilateral side rails as an enabler. The Bilateral siderails were removed and the CCP was not updated to reflect the siderail removal.

Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 7/13/2021, the facility did not ensure that one (Resident #84) of three residents reviewed for Pressure Ulcers was provided with necessary care and services to maintain the highest practicable physical, mental and psychological well-being in a timely manner. Specifically, Resident #84 was readmitted from the hospital on 6/11/2021 with venous stasis ulcers and pressure ulcers. The facility did not assess and treat the ulcers until 6/14/2021, three days after the readmission. The finding is: Resident #84 has diagnoses which include Hypertension and Depression. The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00272845) completed on 7/13/2021 the facility did not ensure a resident with pressure ulcers receives services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #317) of three residents reviewed for pressure ulcers. Specifically, Resident #317 was admitted to facility with a Deep Tissue Injury (DTI) to the sacrum, however, there was no documented assessment of the identified DTI. The finding is: [...]

Inspectors wroteBased on observation, staff interviews and record review during the Recertification Survey completed on 7/13/2021, the facility did not ensure the residents' environment remains free of accident hazards. This was identified for 2 (Resident # 5 and Resident #75) of 2 residents reviewed for accidents. Specifically, 1) On 7/8/2021 Resident #5 was observed with four razors within their room. 2) Oral medications were left unattended by the Registered Nurse (RN), Medication Nurse, in a cup on Resident #75's overbed table. The resident ingested the medications without the nurse being present.

Inspectors wroteBased on interviews and record review during a Recertification Survey and Abbreviated Survey (Complaint # NY 00273922) completed on 7/13/2021, the facility did not ensure that each Certified Nursing Assistant (CNA) implemented the resident care plans as identified through resident assessment for one (Resident #45) of four residents reviewed for Activities of Daily Living (ADL). Specifically, Resident #45 had a physician's order to utilize a Mechanical Lift (Sarita Lift) with assistance of two staff members. The assigned CNA (#6) and the resident both confirmed that the resident was transferred by CNA #6 alone rather than with two staff members as ordered by the Physician. The finding is: Resident #45 was admitted with diagnoses including Multiple Sclerosis, Neuromuscular Dysfunction of bladder, and Generalized Muscle weakness. [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey completed on 7/13/2021 the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 (Resident ##22) of 2 residents observed for wound care. Specifically, the wound care nurse did not follow proper hand hygiene during wound care observation to prevent cross contamination for Resident #22. The finding is: Resident #22 was admitted with diagnoses of Dementia, Peripheral Vascular Disease and Psychosis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had long and short-term memory problems and moderately impaired cognitive skills for daily decision making and had 3 unstageable pressure ulcers. [...]