Long Beach Care Center: Resident Denied Return - CA
Long Beach Care Center violated federal regulations when administrators decided not to readmit Resident 2 following his August 10 hospitalization, according to a complaint inspection completed last month. The facility made the decision without requesting medical records from the hospital or consulting with the resident's physician.
Resident 2 had lived at the facility with diagnoses of schizoaffective disorder and unspecified psychosis. His cognitive skills for daily decision-making remained intact, though he required supervision or assistance with personal care, transfers and walking.
The incident began when Resident 2's roommate refused to return his shoes. A registered nurse documented that Resident 2 "was transferred to GACH on 08/10/2025 for further evaluation after hitting Resident 2's roommate (Resident 1) in the head using his fist."
His family member expressed frustration during an interview with inspectors. "FM 1 stated Resident 2 does not hit someone unprovoked," the report noted. "FM 1 stated it happens because Resident 1 does not want to return Resident 2's shoes."
The family member had appreciated the facility's proximity to his home, making visits convenient. But after learning the facility had arranged placement elsewhere, he decided against pursuing readmission. "As much as the facility was close to FM 1 residence, he will let Resident 2 stay where he was right now and not return to the previous facility because he does not want Resident 2 to be treated wrongly," inspectors documented.
Director of Nursing admitted to inspectors that the decision violated the facility's own policies. She "informed GACH case workers to find another facility for Resident 2 and not to return to the facility because Resident 2 was a danger to others."
This marked the first time Resident 2 had struck another resident.
"The DON stated this was the first-time Residents 2 hit another resident, and he has not done it before," the inspection report stated. Despite this, the interdisciplinary team decided Resident 2 posed a danger to other residents without conducting the required assessment.
The Director of Nursing acknowledged multiple failures in the decision-making process. She admitted there was "no documentation in Resident 2's medical record to show evidence that the facility made efforts to determine if Resident 2 needs cannot be met in the facility and he was a danger to other residents."
She also conceded that "he did not request any documents from GACH to assess resident's needs."
Federal regulations require nursing homes to ensure transfers meet residents' needs and preferences while preparing them for safe transitions. The facility's own Return to Facility Policy mandates that administrators and the Director of Nursing review discharge plans, current conditions, care needs, diagnoses, treatment plans, medication changes, and behavioral or psychosocial support needs.
None of this occurred.
During the inspection interview, the Director of Nursing acknowledged the procedural failures. "The DON stated that he should have requested GACH reports and treatments plan, contact Resident 2's physician before making the decision for Resident 2 not to return to the facility as this was the first-time Resident 2 had a behavior of hitting another resident."
She further admitted that "the facility should evaluate all plans of care, treatment, medications, and services needed of Resident 2 before making a decision not to have Resident 2 back to the facility."
The inspection found that Resident 2 required only minimal assistance with daily activities. His care needs included supervision or touching assistance with oral hygiene, toileting, dressing, transfers and ambulation. His mental health diagnoses did not prevent him from making daily decisions independently.
The facility's hasty decision effectively displaced a resident with mental illness from his established care setting without following required protocols designed to protect vulnerable individuals from arbitrary discharge decisions.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the case illustrates how administrative decisions made without proper assessment can disrupt the lives of residents and their families, particularly those dealing with mental health conditions.
The family member's final comment to inspectors captured the lasting impact: despite the facility's convenience, he would not seek his relative's return due to concerns about how the resident might be treated in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Long Beach Care Center, Inc from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LONG BEACH CARE CENTER, INC in LONG BEACH, CA was cited for violations during a health inspection on August 21, 2025.
The facility made the decision without requesting medical records from the hospital or consulting with the resident's physician.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.