Bixby Towers Post-Acute Rehab in Long Beach: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, Resident 1, an 83-year-old man with heart conditions including atrial fibrillation (an irregular heartbeat) and heart failure, had a Full Code order, meaning staff were to attempt CPR if his heart stopped. In May 2026, CNA 1 brought his breakfast at about 7:30 a.m. and he did not respond. CNA 1 told inspectors she shook him for about five minutes but did not check his breathing or pulse and did not start CPR because she thought he was sleeping.

Inspectors found CNA 1 then called CNA 2, who also shook him without checking his pulse or breathing and left to get the crash cart, which took three to five minutes. CPR started when LVN 3 gave instructions after nurses arrived. CDPH found CPR did not begin until 8 to 10 minutes after Resident 1 was found unresponsive, and that the facility did not follow its own CPR policy. According to the citation, a nursing note said CNA 1 started CPR immediately, but CNA 1 and CNA 2 told inspectors the note did not match what happened.

CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal deficiency was F678 (cardiopulmonary resuscitation) at severity J, that paramedics pronounced Resident 1 dead about 40 minutes after he was found, and that the delay "potentially contributed" to his death. The 2567 report states the facility's Immediate Jeopardy removal plan included retraining nurses, CNAs and therapy staff with hands-on demonstrations, one-on-one retraining for the CNA on duty, a code status audit, a mock code drill and outside CPR training.

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According to the citation, Resident 1, a 94-year-old man with kidney failure and other conditions, had orders requiring CPR if his heart stopped. At about 10:30 p.m. one night in March 2026, CNA 1 found him unresponsive, not breathing and without a pulse. CDPH investigated after a complaint that a delayed emergency response led to the resident's death.

CDPH found that CNA 1, who was CPR certified, did not start CPR or stay with Resident 1. Inspectors found LVN 1 and RN 1 delayed CPR by first checking his blood pressure, oxygen level and eyes and performing a sternal rub (a pain test on the breastbone). According to the citation, 911 was called at 10:37 p.m., paramedics reached his bedside at 10:49 p.m., and Resident 1 was pronounced dead at 11:12 p.m. The department determined the facility did not follow its own CPR policy, which required staff to call a code blue, call 911 and begin basic life support right away.

CDPH issued a Class A citation with a $60,000 penalty. The 2567 report states the federal deficiency was F678 (cardiopulmonary resuscitation) at severity J and that 53 residents with full code status were at risk. Inspectors called an Immediate Jeopardy. The 2567 report states the removal plan included retraining 33 licensed nurses and 43 CNAs on starting CPR at once, calling 911 and never leaving an unresponsive resident alone, one-on-one retraining for LVN 1 and CNA 1, a code status audit, and shift huddles to share code status.

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The 2567 report states that Resident 100 was admitted in June 2025 with a fracture at the base of the spine, respiratory failure and chronic kidney disease. In early July 2025, staff documented a change of condition: the resident was more confused, was cursing and yelling at staff, and was refusing care and breathing treatments. The physician was notified and ordered a urinalysis with culture (a urine test for bacteria) to check for a urinary tract infection, to be collected three days later.

Inspectors found the urine sample was never collected and the physician was not told. According to the 2567 report, LVN 1 said the night shift registered nurse supervisor did not print the order in the lab requisition book or pass it on to the day shift. Inspectors found the facility did not follow its own lab and diagnostic test policy. Two days after the scheduled collection date, the resident was sent to an acute care hospital for evaluation and treatment of her behavior. The 2567 report states the hospital found pyuria (pus in the urine), diagnosed an acute urinary tract infection and treated it with intravenous antibiotics, and the resident stayed about two weeks.

The 2567 report states the federal deficiency for this finding was F684 (quality of care) at severity G. The same survey also cited F607 (developing and implementing abuse and neglect policies) at severity E, F609 (reporting of alleged violations) at severity D, and F610 (investigating, preventing and correcting alleged violations) at severity D. The full narrative is in the linked report.

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The 2567 report states that Resident 1 was admitted in August 2024 with schizophrenia (a chronic mental illness), disorganized thinking, and a history of aggressive and sexually inappropriate behavior. Before admission, he had been treated with 350 mg a day of Clozapine, a drug for schizophrenia. Inspectors found the facility did not have him evaluated by a psychiatrist on admission, did not review his prior Clozapine treatment or tell his physician about it, and did not assess his psychiatric needs. According to the 2567 report, he received no treatment or medication for schizophrenia from admission until October 2024.

Inspectors found that in October 2024, CNA 1 saw Resident 1 sexually assaulting his roommate, Resident 2, and separated them but did not keep watching Resident 1. A few minutes later, CNA 2 saw Resident 1 sexually assaulting Resident 2 a second time. The 2567 report states the CNAs did not follow the facility's policy that residents be kept apart when the suspected perpetrator is a resident.

The 2567 report states the federal deficiencies were F742 (treatment and services for mental and psychosocial concerns) at severity J and F600 (freedom from abuse and neglect) at severity J. CDPH called an Immediate Jeopardy. According to the 2567 report, Resident 1 was sent to a hospital for psychiatric evaluation and discharged from the facility, and Resident 2 was evaluated at a hospital and seen by a psychologist and a psychiatrist. The removal plan included resident interviews about abuse, a review of residents with psychiatric diagnoses, and abuse prevention training for 134 staff.

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The 2567 report states that Resident 1 was admitted in August 2024 with cancer that had spread to the brain, acute kidney failure, and benign prostatic hypertrophy (an enlarged prostate that can make it hard to empty the bladder). His care plan called for staff to watch for and report decreased urine output. Inspectors found the facility's records showed how much fluid he drank over four days but had no documentation of his urine output.

Inspectors found that CNA 2 and CNA 3 did not tell licensed nurses that his diaper stayed dry during their shifts, and that licensed nurses did not assess him for pain, a swollen bladder or urinary retention (inability to empty the bladder). According to the 2567 report, the nurses relied on CNAs to report signs they were not trained to detect, and the facility did not follow its own policy on monitoring fluid intake and output. LVN 1 told inspectors that if a resident's diaper stayed dry for four hours or more, she would check for bladder swelling and inform the physician.

The 2567 report states that Resident 1 had no documented urine output for over 24 hours. Five days after admission he had a seizure and was taken by 911 to an acute care hospital. There he was diagnosed with a urinary tract infection, severe sepsis (a body-wide reaction to infection) and urinary retention, with 1,900 milliliters of urine in his bladder, and was admitted to intensive care. His kidney function returned to normal after a catheter was placed. The 2567 report states the federal deficiency was F684 (quality of care) at severity G.

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According to the citation, Resident 1, a 78-year-old man, was admitted in November 2023 with obstructive sleep apnea (blocked breathing during sleep) and chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow). His physician ordered oxygen at 5 liters per minute continuously to keep his oxygen level above 92 percent, and a CPAP machine (a device that keeps the airway open during sleep) every night.

CDPH found licensed nurses did not give oxygen at the ordered rate, did not put him on the CPAP machine every night, and did not notify his physician when his oxygen level fell below 92 percent. Inspectors found nursing notes showed staff gave oxygen at 4, 3 and 2 liters per minute without a physician's order, and that his oxygen level was recorded at 87, 82 and 81 percent on different days. The director of nursing told inspectors licensed staff removed the CPAP and gave oxygen through a nasal tube instead, and that the physician was not told.

According to the citation, one week after admission Resident 1 was sent to an acute care hospital for shortness of breath and a low oxygen level. He was in the intensive care unit for 15 days and was later hospitalized again for another 15 days. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal deficiency was F695 (respiratory care, including tracheostomy care and suctioning) at severity G.

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