Coral Cove Post Acute in Long Beach: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, Resident 1 was a 63-year-old woman who depended on a ventilator (a machine that breathes for a patient) through a tracheostomy (a surgical opening in the neck into the windpipe). On 6/11/2026 at 8:53 a.m., staff moved her to a portable ventilator for a shower, and her main ventilator was turned off at 8:55 a.m. CDPH found the main ventilator was not turned back on when she returned to her room and was taken off the portable unit. While it was off, it could not sound alarms to warn staff she was not being ventilated. The department determined she went without ventilation for about two hours.

Inspectors found that from 10:37 a.m. to 11:08 a.m. both respiratory therapists on duty were on meal breaks at the same time, and no one was monitoring her airway. At 11:08 a.m. she was found with an orange skin tone, unresponsive, with no pulse and no measurable oxygen level. According to the citation, paramedics pronounced her dead at 11:45 a.m. The 2567 report states these practices resulted in her death and placed seven other ventilator residents at risk.

According to the citation, CDPH classified the violation as Class AA, with a $120,000 penalty. The 2567 report states the facility was cited under F695, respiratory and tracheostomy care, at severity J. According to the report, inspectors called an immediate jeopardy on 7/8/2026 and removed it on 7/10/2026 after checking the facility's removal plan. The report states the plan added a shower and disconnection log that a respiratory therapist completes after each reconnection, and required ventilator residents to stay on their own bedside ventilator, on a rolling stand, during transport and showers.

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The 2567 report states that inspectors reviewed pressure injury care (care for bed sores) and found the facility failed to give Residents 62, 101 and 80 the care needed to heal wounds and prevent new ones. According to the report, redness on Resident 62's right buttock, noted on 6/25/2025, progressed to a Stage III pressure injury (a wound through the skin into deeper tissue and fat) by 6/26/2025. Resident 101 had redness on the tailbone on 6/25/2025 that became an unstageable injury (a wound whose base is covered by dead tissue) the next day and was later reclassified as Stage III.

Inspectors found the facility did not start a wound treatment for Resident 62 when the Stage III injury was identified. Staff did not follow the care plans to reposition Residents 62, 101 and 80 every two hours, and did not provide offloading measures, such as a low air loss mattress, for Residents 62 and 101 once their injuries were found. The report also states the registered dietitian did not reassess those two residents or add nutrition measures, and the interdisciplinary team did not meet to plan wound healing steps for them.

The 2567 report states these practices resulted in preventable pressure injuries for the three residents. The report cited F686, treatment and services to prevent and heal pressure ulcers, at severity G.

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According to the citation, on 2/24/2025 a resident (Resident 1) was not found in her room during morning rounds. CDPH determined she had left the facility without supervision, which the citation calls elopement, sometime between 6 a.m., when she was last seen during a blood pressure check, and 7 a.m. She had dementia and other diagnoses, was under a conservatorship and was known to wander the hallways. Police found her about four miles away at 10:27 a.m., roughly four and a half hours after she was last seen. A paramedic record cited by CDPH says she was walking on a sidewalk confused, speaking incoherently and wearing about 10 layers of clothing. She was taken to an acute care hospital and placed on a medical hold.

CDPH found the facility did not make sure the front door alarm was turned on when the receptionist left at 9 p.m. on 2/24/2025. Inspectors also found her elopement evaluation dated 12/24/2024 was inaccurate. It recorded no history of elopement or wandering, which contradicted an 8/29/2024 evaluation that listed both. According to the citation, staff did not follow the facility's own wandering and elopement policy for identifying residents at risk. According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty.

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The 2567 report states that Resident 1, who took the blood thinners apixaban and aspirin, had an unwitnessed fall on 1/11/2025 during the 11 p.m. to 7 a.m. shift. According to the report, a change of condition note at 8:10 a.m. that day recorded skin tears on his right elbow, right thigh, left lower leg and right shoulder.

Inspectors found the facility did not notify his physician or his responsible party after the fall, did not assess and monitor him or document the incident, and did not report the incident to the next shift. The report attributes the delay in his care to Licensed Vocational Nurse 2's failure to assess and monitor him and to document and report the fall. He was transferred to an acute care hospital on 1/13/2025. According to the report, he was found there with multiple bruises in different stages of healing on both arms, swelling of the right foot, and abrasions (scraped skin) with bruising and clotted blood on the right shoulder, upper arm, elbow and knee. The report states the failure could have left serious injuries unknown to his physician.

The 2567 report states the facility was cited under F580, notification of changes, at severity G. The same survey cited F609, reporting of alleged violations, at severity D. The full narrative of the F609 finding is in the linked report.

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According to the citation, Resident 1 was a 76-year-old woman with glaucoma, legal blindness and dementia. Her fall-risk care plan called for her bed to be kept in the lowest position with floor mats on both sides. CDPH determined she had an unwitnessed fall and was found kneeling on the floor by the left side of her bed, holding the side rail, with the bed in a high position and no floor mats beside it.

She was transferred to an acute care hospital on 10/10/2024. According to the citation, the hospital found a hematoma (a pool of blood under the skin) and deformity below her right knee with loss of feeling, a minimally displaced fracture of the right knee, tibia and fibula (the two lower leg bones), and new compression fractures (collapsed vertebrae) at T11 and T12 in her spine. Inspectors found the facility did not carry out her care plan, did not keep her surroundings as free of accident hazards as possible, and did not follow its own care planning and resident safety policies. The citation states these failures resulted in serious harm.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F656, developing and carrying out a comprehensive care plan, at severity G. The report states the failure to keep her bed low with a floor mat resulted in the fractures to her spine and right leg.

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According to the citation, Resident 1 was a 46-year-old man admitted on 10/26/2023 with diabetes, diabetic retinopathy (eye damage caused by diabetes), glaucoma, blindness in the left eye and normal vision in the right eye. On 3/22/2024 an optometrist recommended that he see a retina specialist and a glaucoma specialist. CDPH found he was not seen by the retina specialist until 8/1/2024, 132 days later, and not seen by the glaucoma specialist until 8/27/2024, 158 days later.

Inspectors found licensed nurses did not act on the referral in time. According to the citation, the social services director, case management and licensed nurses knew about the recommendation, but his primary physician was not properly notified. CDPH also found the facility did not have an updated care plan with steps to prevent vision loss in his right eye, and did not follow its policies on diabetic care, outside referrals and care planning. The citation states his right eye vision deteriorated, leading to vision loss and blindness, and that he developed depression requiring medical treatment, became isolated and lost his independence in daily activities.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F684, quality of care, at severity J, and states the facility failed to ensure a resident with intact right eyesight did not lose that eyesight and become blind.

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According to the citation, Resident 1 was a 70-year-old man admitted on 3/15/2024 with diabetes and acute kidney failure. His physician ordered insulin on a sliding scale. CDPH determined his blood sugar stayed high for four days in a row, from 3/17/2024 through 3/20/2024, with readings between 320 and 450, and his physician was not told.

On 3/20/2024 he became confused and agitated, had deep rapid breathing and an oxygen level of 70% on room air, and could not speak. Inspectors found that a licensed vocational nurse received a report of this change of condition and did not notify the physician, and that licensed nurses did not inform his physician or his representative as the facility's change of condition policy required. According to the citation, he had uncontrolled hyperglycemia (high blood sugar) from 3/17/2024 through 3/20/2024, became lethargic and non-responsive, and died at the facility at 2:10 p.m. on 3/20/2024.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F580, notification of changes, at severity G, finding that the physician was not told about the four days of high blood sugar or about his change of condition on 3/20/2024.

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According to the citation, the department received a complaint on 6/20/2023 that a resident (Resident 1) had been admitted to an acute care hospital with abnormal vital signs, altered mental status and a suspected opioid overdose. CDPH found Resident 1 received seven doses of Norco (hydrocodone-acetaminophen, an opioid pain medication) within 24 hours, while the physician's order allowed four. Resident 1 went to a hospital on 6/19/2023 with a diagnosis of medication overdose and returned with a diagnosis of confusion.

Inspectors found that Resident 2, who had a history of low blood pressure, was given Norco without a blood pressure check. On 6/23/2023 his blood pressure was 87/49, his heart rate was 118 and his oxygen level was 79% to 89% on room air, and he was sent to a hospital for a possible opioid overdose. CDPH also found a licensed vocational nurse did not accurately record the medications given to both residents, and staff did not follow facility policies on medication timing or on checking alertness and vital signs before each opioid dose.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F755, pharmacy services and records, at severity K. According to the report, the problems involved adverse events for three sampled residents and inaccurate medication records for six sampled residents, out of 48 residents receiving narcotic medications. The report also states one nurse prepared medications for Resident 3 that two other nurses then gave without checking them against the physician's order.

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According to the citation, Resident 1 had epilepsy, muscle wasting and walking problems. When physical therapy ended on 3/11/2022, the therapist recommended a restorative nursing program to keep Resident 1 walking. An occupational therapist recommended active range of motion exercises (movements the person makes on their own) for both arms on 6/20/2022, and a physician ordered these exercises for both arms and both legs on 2/16/2023.

CDPH found the facility did not provide these exercises. According to the citation, there were no physician orders for restorative walking exercises after the physical therapy recommendation. Inspectors determined Resident 1 went about 12 months without walking exercises and about nine months without the arm exercises, through 3/31/2023, and had a decline in range of motion in both shoulders and a significant decline in mobility.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F688, range of motion and mobility, at severity K, for five of six sampled residents. The report states restorative nursing services were not provided by certified restorative nursing aides to all eligible residents from 3/11/2022 to 3/31/2023, and the facility had no effective system to watch for declines in residents' joint mobility. It also found the facility did not ensure that an uncertified rehabilitation aide who provided these services was supervised by a licensed therapist.

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