Marlora Post Acute Rehab: Immediate Jeopardy Finding - CA
The citation was classified as immediate jeopardy, meaning inspectors concluded the facility's failure placed residents at risk of serious injury or death. Few residents were affected, according to the inspection record.
The drug at the center of the finding carries a known risk of central sleep apnea, a condition in which the brain temporarily stops sending signals to the muscles that control breathing. The result is repeated pauses in breathing during sleep. The drug is also associated with sleep-related hypoxemia, a dangerous drop in blood oxygen levels that can occur when breathing is interrupted. Neither condition announces itself. A resident experiencing either one may appear simply to be sleeping.
The facility's own written medication policy, dated January 2024, was direct about what staff were supposed to do. If a dosage was believed to be inappropriate, or if a medication was identified as having potential adverse consequences for a resident, the person preparing or giving the medication was required to contact the prescriber, the attending physician, or the facility's medical director to discuss the concern. The policy existed. The question inspectors pursued was whether anyone followed it.
What the inspection record shows is that the required contact did not happen as it should have. Residents received a medication with a documented risk of stopping their breathing during sleep, and the safety step the facility's own protocol demanded, reaching out to a physician to flag the danger, was not taken.
Marlora Post Acute Rehab Hospital is a licensed post-acute and rehabilitation facility in Long Beach. Patients there are often recovering from surgeries, strokes, or other acute medical events, and many carry the kinds of underlying conditions that make respiratory complications especially dangerous. A patient whose brain is already managing the aftermath of a neurological event, or whose lungs are compromised, has less margin when breathing pauses in the night.
Central sleep apnea is distinct from the more commonly known obstructive form of the condition. In obstructive sleep apnea, something physical, tissue or muscle, blocks the airway. In central sleep apnea, the airway is open but the brain simply does not send the signal to breathe. Certain medications are known to cause or worsen the central form. When a drug with that profile is given to a vulnerable patient, the clinical expectation is that someone will notice, weigh the risk, and make a call.
That call was not made.
The inspection was triggered by a complaint, not a routine survey cycle. That means someone, a resident, a family member, or a staff member, contacted regulators with a concern serious enough to prompt investigators to come. The record does not identify who filed the complaint or what specifically they reported. What it documents is what inspectors found when they arrived.
An immediate jeopardy citation is not issued lightly. It requires inspectors to determine that a facility's failure to act was likely to cause or had caused serious harm. The designation triggers an accelerated response requirement from the facility and, if not corrected, can lead to termination from Medicare and Medicaid.
The facility's January 2024 medication policy suggests that at some point, administrators recognized this was exactly the kind of situation that required a structured response. They wrote it down. They gave it a date. They described the scenario, a medication with potential adverse consequences, and they specified the action, contact the prescriber. The gap between that written commitment and what inspectors documented is what produced the citation.
For the residents affected, the nights when their breathing may have paused and no alarm sounded are not recoverable. What happens next at Marlora is a matter of regulatory process. What happened to them is not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marlora Post Acute Rehab Hosp from 2025-11-23 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: August 26, 2026 · Our methodology
MARLORA POST ACUTE REHAB HOSP in LONG BEACH, CA was cited for immediate jeopardy violations during a health inspection on November 23, 2025.
The citation was classified as immediate jeopardy, meaning inspectors concluded the facility's failure placed residents at risk of serious injury or death.
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.