Bixby Towers Post-Acute Rehab: Unlocked Bed Hazard - CA
The resident, identified in inspection records only as Resident 2, had been admitted to the 3747 Atlantic Avenue facility following surgery that removed part of his body. He also lives with end-stage renal disease, the point at which the kidneys have failed completely, and travels to hemodialysis three times a week. Getting in and out of bed is not something he does alone. His assessment from April 2026 noted he requires one to two people to help him with routine daily tasks, including repositioning.
He described the pattern clearly. Every time he came back from dialysis, his bed was unlocked. Three times, while he sat in his wheelchair waiting for a nurse, the bed moved away from him as he tried to get into it. He told inspectors it worried him. It made him feel unsafe.
On May 26, 2026, at 10:50 in the morning, he said exactly that.
Twenty-four minutes later, an inspector stood next to his bed with a certified nursing assistant and pushed against it. The bed moved easily. It was unlocked.
The nursing assistant, identified as CNA 1, said the bed should always be locked to keep Resident 2 safe. A licensed vocational nurse interviewed one minute after that said the same thing: the resident needed supervision when transferring, and his bed should be locked at all times to prevent accidents and injury. A second nursing assistant, CNA 2, said she should have checked the lock because Resident 2 was a fall risk.
The next day, the director of nursing told inspectors it had been CNA 2's responsibility to make sure the bed was locked.
Nobody disputed what happened. Nobody offered an explanation for why it kept happening. The bed was unlocked when inspectors arrived, unlocked when a nursing assistant stood right next to it, and had been unlocked, by the resident's own account, every time he returned from dialysis.
The facility's own policy, last revised in July 2017, states that the environment should be free from hazards including bed safety risks. The policy existed. The staff knew the requirement. The director of nursing knew whose job it was.
The bed still wasn't locked.
For a man who has already lost part of his body to surgery, who depends on a machine three times a week to do what his kidneys no longer can, and who cannot get from a wheelchair to a mattress without another person's help, a bed that rolls is not a minor inconvenience. A transfer that goes wrong, a wheelchair that can't reach where the mattress was a moment ago, a reach that becomes a fall — the distance between an unlocked wheel and a serious injury is short.
Inspectors rated the violation at the minimal harm level, meaning no documented injury had yet occurred. Resident 2 had felt the bed move. He had felt unsafe. He had said so, three separate times, to nobody who fixed it.
The inspection was completed May 27, 2026. He still lives there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bixby Towers Post-acute Rehab from 2026-05-27 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 12, 2026 · Our methodology
BIXBY TOWERS POST-ACUTE REHAB in LONG BEACH, CA was cited for violations during a health inspection on May 27, 2026.
He also lives with end-stage renal disease, the point at which the kidneys have failed completely, and travels to hemodialysis three times a week.
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.