Broadway by the Sea: Physician Order Failures - CA]
A complaint inspection at the facility, located at 2725 E. Broadway, on September 16, 2025, found that staff had failed to follow and carry out physician orders for at least some of the residents in their care. The violation was tagged under F0684, which covers the standard requiring that residents receive care in accordance with professional standards of practice. The level of harm was assessed as minimal harm or potential for actual harm, and the number of residents affected was described as few.
The director of nursing, speaking with inspectors during the survey, did not dispute the premise. She said following physician orders was part of how the facility promoted healing. She said that when a medication order was missed, there was a possibility of causing a delay of care or slowing the progression of healing. She also said it was important to obtain a copy of office visit notes within 72 hours of an appointment to make sure all recommendations and orders were followed through and carried out.
That 72-hour window matters. When a resident sees a specialist or an outside physician and returns to the facility, the notes from that visit carry instructions, medication changes, and follow-up recommendations. If those notes sit unretrieved, orders go unimplemented. Treatments don't start. Wounds don't get the right dressings. Infections get a head start.
The facility's own registered nurse job description, dated December 17, 2021, spelled out the responsibilities clearly. Registered nurses were responsible for initiating requests for consultations and referrals, responding to requests from residents and physicians, consulting with physicians regarding resident evaluation, and planning and developing the nursing services to be performed for each resident. The job description was not ambiguous. The expectations were written down.
Whether those expectations were being met was a different matter.
The inspection report does not name the residents whose care was affected. It does not describe which orders were missed, which medications were skipped, or how long any gap in care lasted before someone noticed. What it records is a pattern recognized by the facility's own leadership as a failure, one with a known mechanism of harm that the director of nursing articulated without being prompted.
Broadway by the Sea is a licensed skilled nursing facility on the eastern edge of Long Beach, a city where the population skews older and the demand for post-acute and long-term care runs high. The facility carries a provider ID of 055894 and operates under the oversight of the California Department of Public Health, which conducted this inspection as a complaint survey, meaning someone, a resident, a family member, or a staff member, raised a concern serious enough to trigger a visit.
Complaint surveys are not routine. They are initiated because something went wrong, or someone believed it did.
The director of nursing's own words during the inspection describe a system that depends on timely retrieval of outside records and consistent execution of physician orders, and a system that, at least for some residents, was not functioning the way it was designed to. She said what should happen. The inspection exists because it didn't.
For the residents affected, the gap between what was ordered and what was done is not an abstraction. A medication not given on schedule. A wound care protocol not updated after a follow-up visit. A referral that didn't get initiated. The inspection report calls the harm minimal or potential. For the person waiting in the bed, the distinction between a delayed order and a missed one is not always easy to see.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broadway By the Sea from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
BROADWAY BY THE SEA in LONG BEACH, CA was cited for violations during a health inspection on September 16, 2025.
A complaint inspection at the facility, located at 2725 E.
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.