Alamitos Belmont Health and Rehabilitation

Inspectors wroteBased on interview, and record review, the facility failed to follow it's policy and procedures (P&P) titled Cardiopulmonary Resuscitation ([CPR] an emergency lifesaving procedure performed when the heart stops beating), which indicated the facility will provide CPR, to any resident requiring such care prior to the arrival of the emergency medical personnel, in the absence of an advance directives or a do not resuscitate (DNR) order for one of three sampled Residents (Resident 93). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure one of three resident's (Resident 10) Potassium Chloride Oral Solution (mineral and electrolyte that regulates fluid balance, sends nerve signals, and regulates muscle contractions) was administered in the correct form.b. Ensure Licensed Vocational Nurse (LVN) 2 indicated the date and time a Lidocaine patch (medication for pain) was applied for one of one resident (Resident 39).c. Document the correct remaining quantity of Morphine Sulfate (potent pain medication), for one of one resident's (Resident 78)The deficient practices had the potential to result in medication errors including residents' diagnoses not being treated, or too much medication being administered.

Inspectors wroteBased on observation interview and record review the facility failed to handle or store food in a sanitary manner by the following:a. Facility kept 30 salt and pepper shakers without labels, covers, and dates after use in the dry food storage area.b. [NAME] 1 and [NAME] 2 did not wear a hair net to fully cover their hair while handling food. These failure has the potential to increase the risk of cross-contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QA&A] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify facility and resident care issues, develop and implement appropriate plans of action to ensure QAA/QAPI committee systemically implemented and evaluated measures to maintain a system to immediately identify residents' code status in an emergency situation that warrants initiation of a resident's CPR without loss of valuable time to implement life saving measures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by failing to:A. Ensure visitors and the staff wore Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for one of three sampled residents (Resident 78) who was on Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism(MDRO) spread where direct contact is likely]. B. [...]

Inspectors wroteBased on interview and record review the facility failed to provide documented evidence of all employees, including physicians, COVID-19 (contagious disease) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 COVID-19 vaccine. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on interview and record review the facility failed to validate 9 of 9 Registered nurses, 23 out of 23 Licensed Vocational Nurses (LVNs), and 68 out of 68 Certified Nurse Assistants (CNAs)'s competency for what to do when taking care of an unresponsive resident who was not breathing and had no pulse. The deficiency resulted in a delay in initiation of Cardiopulmonary Resuscitation ([CPR] an emergency, life-saving procedure performed when the heart stops beating, to maintain blood circulation to the brain) to one of one resident (Resident 93) and the deficient practice placed 40 residents at risk for a delay in receiving immediate CPR interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic medication (medications that affect brain activities associated with mental processes and behavior) was not used unnecessarily for one of three sampled residents (Resident 13) by failing to define and monitor resident specific, measurable target behaviors related to the use of Zyprexa [an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)]for Resident 13. [...]

Inspectors wroteBased on interview and record review the facility failed to create a comprehensive person-centered care plan in a timely manner for one of three sampled residents' (Resident 7) Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure ulcer (damage to the skin and underlying tissue caused by constant, long-term pressure, usually on bony areas like the hips, heels, or tailbone) on the sacrococcygeal (tailbone) area. This failure had the potential to result in delays with the necessary care and services to address Resident 7's wound care needs. During a review of Resident 7's admission Record, the admission Record indicated the facility readmitted Resident 7 on 11/28/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance from underlying illness) and Stage II pressure ulcer of sacral (tailbone) region. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate coordination with the hospice (care focused on providing comfort and support to people who are in the final stages of a terminal illness, rather than trying to cure the disease) provider for one of two sampled residents (Resident 44). This failure had the potential to result in gaps in monitoring, and unmet hospice-related care needs for residents.

Inspectors wroteBased on interview and record review, the facility failed to measure and document one of two sampled resident's (Resident 9) Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacrococcygeal (tailbone) area at least on a weekly basis after being admitted on [DATE]. The deficient practice resulted in poor tracking of the pressure ulcer's healing progress and had the potential to result in delayed care and services.

Inspectors wroteBased on observation, interview, and record review, failed to follow their policy to replace missing dentures and provide a dentist visit for one of three sampled residents (Resident 15). This Failure had the potential to result in Resident 15 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem.

Inspectors wroteDuring interview and record review the facility failed to ensure safe and appropriate discharge planning for one of three sampled resident (Resident 1) by arranging a transfer to an assisted living facility without verifying that the receiving facility could meet the resident's needs and without confirming the accuracy of the discharge destination. This failure to confirm the appropriateness of the discharge and the receiving facility's capability placed Resident 1 at risk for an unsafe and inappropriate transfer, jeopardizing the resident's health, safety, and continuity of care.

Inspectors wroteBased on interview and record review the facility failed to inform one of one sample resident ( Resident 1) that Resident 1's insurance would not cover the cost of a board and care facility ( a small, residential setting that provides housing, meals, and personal care assistance to a limited number of residents). This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet the nutritional needs of 46 of 81 residents on regular texture diets (diets with no restriction) when the residents did not receive three (3) ounce ([oz] unit of measurement) portions. This failure had the potential to result in decreased intake of nutrients resulting in unintended (not done on purpose) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: a. The buttered carrots had no butter flavor. b. The mashed potatoes were bland in taste and had no flavor. This failure had the potential to result in 80 of 81 facility residents, getting food from the kitchen including Residents 27, 42,78, and 82 at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree level four (4) diet (diet consisted of food that are soft with pudding like consistency) received meatloaf that could not hold its shape and puree carrot were weeping water. This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for eight (8) of 81 residents on the puree diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Staff improperly labeled food products. 1. Jello was not labeled with product name. 2. Dry potato was improperly labeled. 3. Resident's food from outside was not labeled with the resident's name. b. Three (3) dented cans were stored with non-dented cans. c. There was chipped, cracked, and rusted kitchen utensils and equipment. 1. Chopping boards had scratches and had sauce splatter stored in the clean area. 2. Fruit cutter had rust. 3. Potato container cover had chips. 4. Can opener had chips. 5. 48 of 48 resident's tray were cracked. d. Kitchen equipment and food preparation surfaces were not cleaned and sanitized. 1. Clean area for storing pots and pans had crumbs and food particles. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not ensuring two (2) of the dumpster's (a large trash metal container designed to be emptied into a truck) were not overflowing with trash, and the dumpster lids remained closed. This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 80 of 81 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment ([PPE], clothing or equipment that protects the wearer from injury or illness) while providing direct resident care for one of three sampled residents (Resident 70) who was on enhanced barrier precaution/protection ([EBP], infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of causing an outbreak in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff and physician were notified in a timely manner when one out of six residents (Resident 47) presented with decreased range of motion (ROM- full movement potential of a joint) of the bilateral (both) ankles. As a result of this deficient practice, Resident 47 had a delay in services including being seen and evaluated by physical therapy (PT - profession aimed in the restoration, maintenance, and promotion of optimal physical function) to see what services he required.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a level 2 Preadmission Screening and Resident Review (PASRR, Level 2 Evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed) evaluation for one of six sampled residents (Resident 47) who had a diagnosis of depression (a mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being). This deficient practice had the potential to cause a delay in services for Resident 47.

Inspectors wroteBased on interview and record review the facility failed to ensure one of six sampled residents (Resident 8) received her Insulin (a medication that regulates blood sugar levels and is essential for life) as ordered by the physician. This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when blood sugar level drops too low).

Inspectors wroteBased on interview and record review, the facility failed to accurately assess, monitor the effectiveness of current pain management, and reassess the pain for one of six sampled residents (Resident 47) who was receiving pain medications. This deficient practice had the potential for resident 47 to experience unnecessary pain.

Inspectors wroteCross Reference: F658 Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 8) was free from a significant medication error by failing to follow the physician's ordered parameters (specific instructions) when administering insulin (a hormone medication that regulates blood sugar levels and is essential for life). This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when your blood sugar level drops too low).

Inspectors wroteBased on record review and interview, the facility failed to provide Restorative Nursing Aide program (RNA, nursing aide program that helps residents maintain their function and joint mobility) to one of three sampled residents (Resident 1) when Resident 1 was not discharged home on 2/6/2024 and continued to stay in the facility until 3/6/2024. Resident 1 did not start receiving RNA services until 2/19/2024. This deficient practice placed Resident 1 at risk for a decline in ambulation and range of motion ([ROM] how far you can move or stretch a part of your body, such as a joint or a muscle). Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis of history of falling and weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy to notify the physician for one of three sampled residents (Resident 2), when the facility did not have Resident 2's ordered medications available and did not administer Amiodarone (drug that works to keep heart rhythm regular), Apixaban (drug used to prevent blood clots), Doxazosin (drug used to keep heart rhythm regular) and Metoprolol (drug used to treat high blood pressure) as ordered. This failure had the potential to cause a delay in needed assessments, services, and treatments for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive resident centered care plan interventions for one of three sampled residents (Resident 1), who had a history of frequent falls between the hours of 4 am and 8 am due to the need to urinate. This failure resulted in Resident 1 sustaining multiple falls on 12/12/2023, 12/18/2023, 1/10/2024, and 1/16/2024 which had the potential to injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was in severe back pain and was at the facility for pain management, received Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain) 10/325 milligram ([mg] a unit of weight measurement), for severe pain, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who had a history of back surgery, and was admitted to the facility for pain management with an order for Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain)10-325 milligrams ([mg] a unit of measurement) for severe pain, had the order for Norco refilled in time enough to ensure its availability for 1 of 3 sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows: 1. Resident 44 received both medications carvedilol (a medication that works by slowing down your heart rate and making it easier for your heart to pump blood around your body) 3.125 mg (unit of measurement) one tablet every twelve hours and nifedipine ER (a medication that works by affecting the movement of calcium into the cells of the heart and blood vessels) 90 mg one tablet by mouth daily and Licensed Vocational Nurse (LVN) 6 did not check blood pressure readings and apical pulse (AP- a pulse point on your chest that gives the most accurate reading of your heart rate). 2. [...]

Inspectors wroteFACILITY Based on observation, interview, and record review, the facility failed to ensure a. that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows: 1. Resident 44 received both medications carvedilol (a medication that works by slowing down the heart rate and making it easier for your heart to pump blood around your body) 3.125 milligram (mg a unit of measurement of weight) one tablet every twelve hours and nifedipine extended release (a medication used to treat high blood pressure) 90 mg one tablet by mouth daily and Licensed Vocational Nurse (LVN) 6 did not check blood pressure readings and apical pulse (AP- a pulse point on your chest that gives the most accurate reading of your heart rate) before administering the medications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate and evaluate the food preferences for one of eight sampled residents (Resident 71). This deficient practice had the potential for Resident 71 to have insufficient food intake and significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation when: 1. Potatoes and onions prepared for Mechanical soft diet (food texture modified for residents who have chewing or swallowing difficulties) were cut into large pieces and not chopped according to recipe and spreadsheet (food portion and service guide) instruction and mechanical soft diet guidelines. 2. Fortified diets (diet enhanced to increase caloric content) were not prepared and were not served to residents who were on fortified diet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed by staff for five of eight sampled residents (Residents 59,71,15, 131 and 279) by failing to: 1. Ensure Resident 59's a gastrostomy tube (G-tube), a tube inserted through the belly that brings nutrition directly to the stomach and dressing (a pad applied to a wound to promote healing and protect from future harm) were applied as indicated in the care plan and physician's order. 2. Ensure Resident 71's and Resident 15's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) mask and nasal cannula (a device used to deliver supplemental oxygen placed directly on the resident's nostrils) was properly stored or changed as indicated in the facility's policy and procedure (P&P). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and calibrate (process that ensures the reading and functionality of a device is accurate and in full working order) the sit to stand lift (a mechanical device used to assist a resident move from a seated position to a standing position) for resident use in accordance with manufactures guidelines. This deficient practice had the potential to cause injury to any resident who used this equipment as part of their therapy treatment.

Inspectors wroteBased on observation, interview, and record review the facility's interdisciplinary team (IDT), a coordinated group of experts from several different fields who work together, failed to ensure one of eight residents (Resident 385) was allowed to keep medications at the bedside without a physician's order and without being assessed to determine if the resident was capable to self-administer medications. These deficient practices placed Resident 385 at risk for medication errors and had the potential for unsafe medication administration for other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of eight sampled residents (Resident 1). This deficient practice had the potential to delay Resident 1 from receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of eight sampled residents (Resident 1) to address decreased physical mobility and weakness when Restorative Nursing Aide services (RNA, nursing program that uses restorative nursing aides to help residents maintain their function and joint mobility) were discontinued. This deficient practice had the potential to negatively impact the provision of necessary care, treatment, and services for Resident 1 and cause a decline range of motion (ROM, full movement potential of a joint), contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) development, and overall decline in functional ability.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sample residents (Resident 70) with a history of urinary retention (a sudden inability to urinate) was provided services to meet the resident needs and make a necessary appointment to see an urologist ( a doctor who specializes in the study or treatment of the function and disorders of the urinary system) as ordered by the physician. This failure put Resident 70 at risk for further urinary retention and had the potential to lead to further urinary complications like urinary tract infection (when bacteria enter the body and infects the urinary tract), benign prostate hypertrophy (enlarged prostate [ the top portion of the tube that drains urine from the bladder]), fever and pain.

Inspectors wroteBased on interview and record review, the facility failed to treat one of two sampled residents (Resident 40) with a diagnosis and verbalizations of depression. This deficient practice resulted in Resident 40 not receiving the proper assessment, necessary treatment and resources for her diagnosis of depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one out of eight sampled residents (Resident 15) with meals that accommodated their food preferences. This deficient practice had the potential to result in decreased meal intake, lead to weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of two sampled residents (Resident 428). Resident 428 was prescribed antibiotic drug without meeting the criteria, after being screen for urinary tract infection ([UTI]an infection in any part of the urinary system). This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.