North Long Beach Post Acute: Fall Notification Delay - CA
The incident occurred at North Long Beach Post Acute on August 29 at 4:39 a.m., when a certified nursing assistant discovered Resident 1 sitting on the floor beside her bed, facing the wall. The resident's responsible party wasn't contacted until 7 a.m.
Resident 1 has severe dementia and depends entirely on facility staff for basic daily activities like bathing, dressing and toileting, according to her assessment records. She was admitted to the facility with a diagnosis of dementia, described in her medical records as "a progressive state of decline in mental abilities."
The Director of Nursing received a phone call from Licensed Vocational Nurse 1 after the resident was found on the floor. During a September 10 interview with federal inspectors, the nursing director said the LVN "was scared to report Resident 1's fall to the RP."
The nursing director had to guide the licensed nurse "to ensure everything was completed for Resident 1 post fall," she told inspectors. She acknowledged that "Resident 1's RP should have been notified at the time of the incident."
The resident's responsible party confirmed receiving the facility's phone call about the fall at 7:08 a.m., according to interviews with inspectors. Federal regulations require nursing homes to immediately notify residents' families or representatives of accidents and significant changes in condition.
The facility's own policy, dated August 25, 2021, states that staff "must inform the resident representative as soon as possible where there is an accident involving the resident."
The two-and-a-half-hour delay "had the potential to delay the RP's involvement in care decisions and compromised the residents' right to informed participation in their care," inspectors found.
Federal investigators cited the facility for failing to meet notification requirements, noting that the deficient practice affected the resident's fundamental rights. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
For residents with severe cognitive impairment like Resident 1, family involvement in care decisions becomes particularly critical since the residents cannot advocate for themselves or make informed choices about their treatment.
The inspection was conducted in response to a complaint filed about the facility. Inspectors reviewed the resident's admission records, assessment data, and change-of-condition documentation to piece together the timeline of events.
The facility's change-of-condition note, timed at 4:39 a.m., documented that Resident 1 was "found by a Certified Nurse Assistant (CAN unknown) sitting on the floor to the right side of the bed facing the wall." The same note indicated the responsible party wasn't notified until 7 a.m.
During the investigation, inspectors interviewed both the resident's responsible party and the facility's Director of Nursing to verify the timeline and understand why the delay occurred.
The nursing director's admission that she had to guide the licensed nurse through proper fall response procedures raises questions about staff training and preparedness for handling incidents involving vulnerable residents.
Falls among nursing home residents, particularly those with dementia, require immediate assessment and family notification because they can indicate changes in medication effects, underlying medical conditions, or environmental hazards that need prompt attention.
The resident's severe cognitive impairment, documented in her Minimum Data Set assessment just three days before the fall, meant she was entirely dependent on staff advocacy and family involvement for her care and safety.
Resident 1's responsible party now knows that when his family member fell in the early morning hours, scared staff delayed calling him for over two hours while she remained on the floor beside her bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Long Beach Post Acute from 2025-09-10 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 19, 2026 · Our methodology
North Long Beach Post Acute in LONG BEACH, CA was cited for violations during a health inspection on September 10, 2025.
The resident's responsible party wasn't contacted until 7 a.m.
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.