Resident 16 remained on the restrictive mattress at North Long Beach Post Acute despite his physician canceling the order on July 18, 2023. When inspectors arrived in June 2024, staff discovered they had no current authorization for the device that kept the resident confined to the center of his bed.
"The wedge is in the bed and the resident cannot remove it," Certified Nursing Assistant 4 told inspectors. "It restricts the resident's movements and is not comfortable for the resident."
The bolster mattress violation was one of several serious deficiencies federal inspectors found during their June 28, 2024 survey of the facility. The inspection revealed a pattern of inadequate oversight that put vulnerable residents at risk.
Staff had no idea why Resident 16 was still using the restraint device. Licensed Vocational Nurse 2 admitted she could not find an order or consent for the bolster mattress and "does not know why the resident has that bed."
The facility's Director of Nursing acknowledged the problem during the inspection. "Any device utilized need a consent and residents who use the device needs to be assessed as needed and quarterly to see if they still need it or not," she told inspectors.
Resident 16 suffered from chronic heart failure, dementia, and psychosis. His medical records showed he was dependent on staff for all daily activities and had moderately impaired cognitive skills. The bolster mattress had built-in wedges on both sides that prevented him from moving freely or getting out of bed independently.
A second resident faced similar problems. Resident 56 was supposed to have his bolster pads removed on June 17, 2024, according to physician orders. But when inspectors observed his room on June 24 and 25, the restrictive devices remained in place.
"The bolster pads should have been discontinued and removed from resident's bed when it was ordered by the physician on 6/17/2024," the Assistant Minimum Data Set Coordinator admitted to inspectors.
The facility's own policy required physician orders and consent forms before using any restraint device. Staff acknowledged that bolster mattresses restricted residents' movements and could lead to isolation or depression.
While residents remained in unauthorized restraints, the facility employed a registered nurse supervisor with a troubling disciplinary history. The California Board of Registered Nursing had taken four administrative actions against her license, including findings of gross negligence.
According to board documents from August 10, 2015, the nurse had been disciplined for "screaming at the patient and slapping patient's hands" in one incident. A second disciplinary action involved professional misconduct with co-workers.
The facility's hiring practices failed to catch these red flags. The Director of Staff Development told inspectors that licensed nurses were hired after verifying their licenses were active, but administrators admitted they never read the disciplinary documents from the state nursing board.
"The background check of RNS 1 was clear and the facility was an equal opportunity and they do not discriminate and give everyone a chance to be hired in the facility," the Administrator said.
The nurse supervisor was suspended for two days in May 2024 following an allegation of abuse against a resident at the facility.
The facility's own policy required thorough background checks and stated that applicants with histories of abuse, neglect, or mistreatment "should not be employed or contracted."
Beyond restraint and hiring violations, inspectors found the facility failed to follow through on medical care. Resident 102 had been requesting to see an orthopedic specialist for chronic left knee pain but staff never scheduled the appointment despite a physician's order on June 25, 2024.
The resident described constant pain and frustration during interviews with inspectors. "He started to cry while thanking RNS 1 for calling the physician for the orthopedic specialist consultation because Resident 102 felt frustrated about the left knee," according to inspection notes.
Resident 102 had undergone knee surgery in July 2023 but developed a severe contracture that left his leg permanently bent. He told inspectors he "laid in bed every day because the facility staff cannot put Resident 102 in a wheelchair" and became tearful explaining he couldn't return home because he couldn't walk.
The facility's physiatrist had recommended an orthopedic surgeon referral, but nursing staff failed to schedule the appointment. The Director of Social Services wasn't even aware of the physician's order during the inspection.
Additional violations included inaccurate resident assessments that sent wrong information to federal databases. Two residents' range of motion limitations were incorrectly reported, potentially affecting their care plans and treatment services.
The facility also failed to ensure residents knew how to file grievances. During a resident council meeting, one resident with intact cognition stated he didn't know how to file a complaint or who to approach for help with concerns.
Four residents with mental health diagnoses never received required specialized evaluations. Despite having conditions like schizophrenia and schizoaffective disorder, the facility failed to request Level II mental health assessments that could have provided additional psychiatric services.
Resident 89 was prescribed Seroquel for schizoaffective disorder but never received the required screening after his new diagnosis. "If there was a new diagnosis, a PASARR should be done to check if there was a need for a level II assessment," the MDS Coordinator admitted. "The PASARR was not done due to an oversight on their part."
The violations at North Long Beach Post Acute illustrate systemic failures in resident protection, from unauthorized restraints to inadequate hiring practices to missed medical appointments. Residents remained trapped in restrictive devices while a nurse with a history of patient abuse continued working with vulnerable populations.
Resident 102's situation exemplified the human cost of these failures. Nearly a year after knee surgery, he remained bedridden with severe contractures, crying from pain and frustration while facility staff failed to schedule the specialist appointment he desperately needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Long Beach Post Acute from 2024-06-28 including all violations, facility responses, and corrective action plans.
