Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alamitos Belmont Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with ESRD, anemia, DM, and dementia was found unresponsive, not breathing, and without a pulse, but CNA and LVN staff delayed CPR and EMS activation. The resident was full code per POLST, yet CPR was not started right away after the resident was discovered pulseless. Interviews confirmed the delay, and the DON stated staff should have initiated CPR immediately.
Medication administration and controlled substance documentation were inaccurate for three residents. One resident received potassium in the wrong form instead of the ordered oral solution, another resident’s Lidocaine patch was applied without the date and time being marked, and a third resident’s morphine tracking record did not consistently show the amount removed or remaining in the bottle. The DON stated staff should document controlled medications accurately on the tracking form and eMAR.
Food was not stored and handled in a sanitary manner when 30 salt and pepper shakers were found in the dry storage area without labels, covers, or dates, and two cooks were observed with hair not fully covered while handling food. The DS and RD confirmed the storage and hair coverage issues, and facility policy required dry foods to be labeled, covered, dated, and staff hair to be completely covered.
A QA&A/QAPI failure led to delayed CPR for a resident who was found unresponsive, pulseless, and not breathing. CNA 1 notified an LVN, another LVN verified no vital signs, and staff checked the chart for code status before starting CPR, resulting in about a 30-minute delay. The DON and ADM stated there was no system to ensure timely CPR, and the DSD stated staff should have started CPR right away.
Infection control measures were not implemented for a resident on EBP when an LVN performed high-contact care without gown and gloves, and a family member at the bedside was not instructed to use PPE. The resident had a Foley catheter and required extensive assistance with ADLs. The facility also failed to test two residents who developed respiratory symptoms and did not place them on TBP/droplet-contact isolation while COVID-19 was being ruled out, despite SBAR documentation of cough and sore throat and facility guidance requiring immediate isolation and testing.
The facility failed to document COVID-19 vaccination status for all employees, including physicians, and failed to document education on the benefits and potential side effects of the 2025 to 2026 COVID-19 vaccine or the offering of that vaccine to staff. The IPN stated the roster did not include physicians and that there was no documented evidence that physicians or licensed practitioners received the required education or vaccine offer. The DON stated staff need to be educated and the current COVID-19 booster should be offered to staff.
The facility failed to validate CPR competency for RNs, LVNs, and CNAs. A resident with ESRD, anemia, DM, and dementia was found cold, unresponsive, not breathing, and without a pulse, but staff delayed CPR while verifying findings and checking the resident’s code status. The DSD and DON stated staff competency for timely CPR and response to unresponsive residents was not ensured or validated.
A resident with Alzheimer's disease, schizophrenia, and cerebral infarction was prescribed Zyprexa for reported hallucinations, but the facility did not define or monitor resident-specific, measurable target behaviors. The RN supervisor stated no hallucinations were observed or documented, and the PNP said the medication was based on family-reported beliefs that people were pulling the resident's legs. The MDS coordinator and DON stated the behavior monitoring should have been specific and measurable, but the charting remained general and did not reflect clear target behaviors for the psychotropic medication.
Delayed Care Plan for Stage II Pressure Ulcer: A resident was readmitted with a Stage II sacrococcygeal pressure ulcer and impaired cognition, but the initial care plan did not include interventions for the wound. The RN Supervisor stated the pressure ulcer was not addressed in the care plan until 10 days later, and the DON stated the care plan should be developed promptly because staff follow it.
A resident with a hospice order, severe cognitive impairment, and extensive ADL assistance needs had scheduled hospice aide and RN visits that did not match the visit records. The hospice calendar and sign-in/notes lacked documentation that the missed visits were rescheduled, completed later, or otherwise accounted for, and staff interviews confirmed the facility did not adequately coordinate or oversee hospice services as required by the hospice agreement.
Failure to Measure and Document a Stage II Pressure Injury Weekly: A resident with CKD, anemia, and protein calorie malnutrition was admitted with an unhealed Stage II sacrococcygeal pressure injury. The admission record documented the wound’s initial size and appearance, but the only measurement was taken on admission and no weekly measurements were documented for 28 days. An LVN and the DON both confirmed the wound should be measured at least weekly, and the facility policy required weekly assessment and measurement of areas of skin alteration.
Missing Dentures Not Replaced or Referred for Dental Visit: A resident with dysphagia and dementia was observed without natural teeth and without dentures at the bedside, and she reported discomfort while eating and embarrassment when speaking. Records showed dentures were documented on admission but absent on readmission from the hospital. The RNS, SSD, and DON stated the dentures were lost during hospitalization, the issue was not communicated to SSD, and a dental visit for replacement was not arranged within the expected timeframe.
A resident with complex medical needs and dependence on staff for daily care was scheduled for discharge to an assisted living facility without proper verification that the facility could meet their needs or confirmation of the discharge destination. The receiving facility was not expecting the resident, was not equipped to provide the required care, and confusion existed regarding the resident's identity and admission, resulting in the discharge being delayed.
A resident who required assistance with hygiene and was able to make their own decisions was discharged to a board and care facility without being informed that their insurance would not cover the cost. The resident was told by social service staff that insurance would pay, but upon arrival learned their social security check would be used, resulting in unexpected financial obligations and psychosocial distress.
The facility failed to provide consistent 3-ounce portions of meatloaf to 46 residents on regular diets, as specified in the menu. Observations revealed varying portion sizes, with some as low as 2.5 ounces. Staff initially misjudged the portion size, leading to adjustments based on resident complaints. The Dietary Supervisor and Registered Dietitian stressed the importance of following the menu for adequate nutrition.
The facility failed to prepare food that conserved flavor and appearance, as observed in bland buttered carrots and mashed potatoes. Multiple residents, including those with chronic conditions and specific dietary needs, reported dissatisfaction with the food. The Dietary Supervisor confirmed the lack of flavor, indicating a possible deviation from standardized recipes.
The facility failed to prepare puree diets correctly for residents with dysphagia, as observed with the puree meatloaf and carrots not meeting the required consistency. The puree meatloaf could not hold its shape, and the puree carrots were watery, which did not align with the diet manual's standards. This deficiency was confirmed by the dietary supervisor and registered dietitian, who noted the potential risk of aspiration for residents with difficulty swallowing.
The facility failed to ensure safe food storage and preparation, with issues such as improper labeling, dented cans, and unsanitary kitchen equipment. Staff did not perform hand hygiene, and food temperatures were not checked, leading to potential foodborne illnesses among residents.
The facility failed to properly dispose of garbage, with two dumpsters found overflowing and unable to close, as observed by the Dietary Supervisor and Environmental Services Director. This improper disposal could attract pests and rodents, posing a health risk to residents. The facility's policies and the Food Code 2022 emphasize proper disposal to prevent contamination, which was not followed.
A facility failed to ensure staff wore appropriate PPE while caring for a resident on enhanced barrier precautions due to a G-Tube. A CNA was observed without a gown, only wearing gloves, and did not perform hand hygiene after care. The resident had multiple diagnoses and required PPE for high-contact activities. Staff interviews and facility policies confirmed the need for PPE to prevent infection spread.
A resident with Parkinson's Disease and prostate cancer experienced decreased ROM in both ankles, but the facility failed to notify nursing staff and a physician in a timely manner. An RNA noticed increased stiffness in the resident's ankle in mid-October but only informed a physical therapist who no longer worked there, neglecting to report to nursing staff. This delay in communication postponed necessary evaluations and interventions.
A facility failed to follow up on a Level 2 PASRR evaluation for a resident with depression, Parkinson's Disease, and prostate cancer. Despite a positive Level 1 screening indicating the need for further evaluation, the facility did not respond to attempts to complete the Level 2 assessment. The DON was unaware of the communication attempts, leading to a closed case and potential delay in services.
A resident with type 2 diabetes and chronic kidney disease did not receive insulin as ordered by the physician. The resident's MAR showed that Insulin Glargine was administered when blood sugar levels were below the physician-ordered threshold of 150 mg/dL. The DON confirmed that this practice was against the physician's parameters, posing a risk for hypoglycemia, and emphasized the importance of following physician orders.
A resident with chronic pain conditions was inadequately assessed and monitored for pain management in an LTC facility. Despite being prescribed multiple pain medications, the resident's pain was not effectively managed, with inconsistencies in pain assessment and documentation. The MAR showed a lack of reevaluation after medication administration, and the resident reported severe pain that was not addressed timely. Staff interviews confirmed the deficiency in pain management practices.
A resident with type 2 diabetes and chronic kidney disease received Insulin Glargine despite physician orders to hold it if blood sugar was below 150 mg/dL. The insulin was administered multiple times when the resident's blood sugar was below this threshold, posing a risk for hypoglycemia. The DON confirmed the error, noting the importance of adhering to physician orders to prevent adverse effects.
A resident with a history of falling and weakness did not receive timely Restorative Nursing Aide (RNA) services after their discharge plan changed. Despite the resident's care plan aiming to improve their ADL function, RNA services were delayed until 2/19/2024, putting the resident at risk for a decline in range of motion and strength.
Delayed CPR Response for Full-Code Resident
Penalty
Summary
The facility failed to follow its CPR policy when a resident who was a full code was found unresponsive, not breathing, and without a pulse. The resident had diagnoses including end stage renal disease, anemia, diabetes mellitus, and dementia, and the MDS indicated severe cognitive impairment and dependence on staff for ADLs. The resident’s POLST indicated full code status with resuscitation/CPR. According to the record, CNA 1 found the resident cold to touch and unresponsive, then left to find LVN 1. LVN 1 and LVN 2 assessed the resident and found no detectable vital signs and no pulse. The nursing progress note indicated the resident was last seen coughing earlier that morning, and the resident was later pronounced dead. The EMT run sheet showed EMS was dispatched at 6:05 a.m., arrived at 6:10 a.m., and the resident was pronounced dead at 6:15 a.m. Interviews with LVN 1 and LVN 2 showed delays in response. LVN 1 stated she initiated CPR about 30 minutes after the resident was found unresponsive, and LVN 2 stated there was a delay in initiating CPR and that staff could have started CPR as soon as the resident was observed unresponsive and without a heartbeat. The DON stated the staff should have tried to determine the resident’s code status and initiated CPR right away, and also stated there was no system in place for emergency situations such as this to ensure timely CPR. The facility’s CPR policy required staff to check responsiveness, breathing, and pulse simultaneously, activate EMS, page or yell for Code Blue, call 911, and start CPR immediately for a resident in cardiac or respiratory arrest.
Medication Administration and Controlled Substance Documentation Errors
Penalty
Summary
Medication administration was not carried out in the form ordered for one resident with anemia, sick sinus syndrome, atherosclerotic heart disease, and atrial fibrillation. The resident had an order for Potassium Chloride Oral Solution, 15 milliliters by mouth twice daily for potassium supplementation while on Lasix, but during observation the LVN administered potassium in pill form instead of the ordered liquid form. The LVN later stated the wrong potassium form had been given and that the liquid form, not the pill form, should have been administered. A second resident with weakness, peripheral vascular disease, and moderately impaired cognitive skills for daily decision-making had an order for Lidocaine HCl External Patch 4% to be applied to both knees once daily. During observation, the LVN applied the patches to the resident’s knees without labeling them with the date and time of application. The LVN later stated she did not indicate the date and time on the Lidocaine patch. A third resident with anemia, DM, and HTN had an order for morphine sulfate oral solution with specific doses based on pain level or shortness of breath. During concurrent observation, interview, and record review, the resident’s morphine bottle contained approximately 10 mL, while the controlled medication tracking system showed 10.50 mL remaining the previous day and did not indicate how much was left after the last dose. The LVN stated nurses were pulling medication from the bottle without documenting how much was left, and the DON stated staff should document the amount taken out and the amount remaining on the tracking form and eMAR.
Food Storage and Hair Coverage Deficiencies
Penalty
Summary
Food was not handled and stored in a sanitary manner in the dry food storage area when 30 salt and pepper shakers were observed without labels, covers, or dates after use. During a concurrent observation and interview with the Dietary Supervisor, 15 white and 15 black powdery substances were seen inside glass shakers with holes on the metal tops, and the covers had fallen off because the shakers were placed upside down. The Dietary Supervisor identified the items as salt and pepper shakers and stated dietary staff should empty and wash the containers after every use before storing them, and that opened and unlabeled food items should not be stored in the dry food storage area. Food service staff also did not fully cover their hair while handling food. During a concurrent observation and interview in the kitchen, the Registered Dietician observed that one cook's hair net did not fully cover her head, with hair exposed on both sides and the back. Another cook was wearing a hair cover with exposed hair on both sides and the back of her head. The Dietary Supervisor stated that if staff do not fully cover their hair, hair can fall into food and cause food borne illness. The DON stated kitchen staff need to cover all their hair with hair nets while working in the kitchen for infection control and sanitary reasons. The facility's Dress Code policy required hair to be completely covered, and the Storage of food and supplies policy required dry bulk foods and opened dry food items to be labeled, covered, and dated.
Delayed CPR Due to Code Status Identification Failure
Penalty
Summary
The facility's QA&A/QAPI committee failed to identify and address a systemic issue involving the immediate identification of a resident's code status during an emergency. During the early morning hours, CNA 1 found Resident 93 unresponsive and unable to be awakened. LVN 1 and LVN 2 were notified and checked the resident, but staff did not begin CPR right away. LVN 1 stated she checked for vital signs and a carotid pulse and found none, but waited about 30 minutes after the resident was found unresponsive before starting CPR. LVN 2 stated LVN 1 went to check the chart for code status and called EMS, and that CPR was delayed; she also stated that if staff had known the resident's code status, CPR could have started as soon as the resident was observed unresponsive and without a heartbeat. The DON stated the nurses' progress note did not show that CPR was started immediately when CNA 1, LVN 1, and LVN 2 found the resident unresponsive, and stated there was no system in place for emergency situations to ensure timely CPR. The ADM stated staff had to check the resident's code status before initiating chest compressions and acknowledged that staff did not immediately do CPR when the resident was found unresponsive. The DSD stated staff should have performed CPR right away when the resident was pulseless and not breathing, and that the facility's system was for licensed staff to check code status in the electronic medical record and initiate CPR until EMS took over.
Infection Control Failures With PPE Use and COVID-19 Symptom Response
Penalty
Summary
The facility failed to implement infection control measures for a resident on Enhanced Barrier Precautions. Resident 78 had diagnoses including UTI, uterine cancer, DM, and chronic kidney disease, and the record showed fluctuating capacity to understand and make decisions. The resident’s MDS indicated dependence on two or more staff for multiple activities of daily living, and the care plan identified use of Enhanced Barrier Precautions because of Foley catheter placement and risk for UTI. During a concurrent observation and interview, an LVN was in Resident 78’s room checking blood pressure while her uniform touched the resident’s bed linen. The LVN wore a mask but did not wear a gown or gloves. The resident’s family member was at the bedside holding the resident’s hands after the blood pressure check and also did not wear PPE. EBP signage was posted at the room entrance. The LVN stated she should have worn a gown and gloves because checking blood pressure was a high-contact activity and should have educated the family member about wearing PPE. The family member stated staff had not told her to wear PPE and that no one had provided education or information about PPE use in the room. The IPN and DON stated that staff should wear mask, gown, and gloves for high-contact care under EBP and that visitors should also be educated and asked to wear PPE. The facility also failed to test and place two residents on transmission-based precautions when they developed respiratory symptoms. Resident 10’s record showed diagnoses including anemia, sick sinus syndrome, atherosclerotic heart disease, and atrial fibrillation, and the SBAR form documented a productive cough. Resident 11’s record showed diagnoses including cellulitis, asthma, and chronic kidney disease, and SBAR forms documented a sore throat and later a dry cough. Review of the MARs showed monitoring for COVID-19 signs and symptoms, but no COVID-19 test was conducted for either resident. The IPN stated both residents should have been tested for COVID-19 and placed on droplet/contact isolation until COVID-19 was ruled out. The DON stated the facility should follow local public health guidance, and the facility policy and local health guidance indicated residents with symptoms consistent with COVID-19 should be isolated immediately and tested.
Incomplete COVID-19 Vaccination Education and Documentation for Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians, and failed to document education on the benefits and potential side effects of the 2025 to 2026 COVID-19 vaccine and the offering of that vaccine to staff. During a concurrent interview and record review, the Infection Prevention Nurse stated there was no documented evidence that physicians or licensed practitioners received education on benefits and side effects or were offered the 2025 to 2026 COVID-19 booster vaccine. The Infection Prevention Nurse also stated the staff vaccination roster did not include physicians and should include everyone with direct access to residents. During a later interview, the Director of Nursing stated staff need to be educated and the current COVID-19 booster should be offered to staff. Review of the facility policy titled Immunizations - Staff, revised 7/2023, indicated staff includes licensed practitioners.
Failure to Validate CPR Competency and Delay in CPR Initiation
Penalty
Summary
The facility failed to validate the CPR competency of 9 of 9 RNs, 23 of 23 LVNs, and 68 of 68 CNAs for responding to an unresponsive resident who was not breathing and had no pulse. The record review showed no documented evidence in the personnel files for CNA 1, CNA 2, LVN 1, and LVN 2 that the facility had validated staff competency on CPR or on how to respond to residents who were unresponsive, had no pulse, and had no respirations. The facility’s Skills Awareness and Competency form, revised [DATE], also did not show staff CPR skills validation or validation of how to respond to residents with no pulse and no respirations. Resident 93 was admitted with ESRD, anemia, DM, and dementia, and the MDS indicated the resident was severely cognitively impaired and dependent for activities of daily living. During interview, LVN 2 stated that when Resident 93 was found cold, unresponsive, with no pulse, and not breathing, LVN 1 and LVN 2 waited to verify each other’s findings and then went to the computer to determine the code status before starting CPR, and LVN 1 stated CPR was not started immediately. The DSD and DON both stated the facility did not ensure or validate staff competency for timely CPR and for handling residents who were unresponsive, had no pulse, and had no respirations.
Psychotropic Medication Used Without Resident-Specific Target Behaviors
Penalty
Summary
The facility failed to ensure that a psychotropic medication was not used unnecessarily for one resident by not defining and monitoring resident-specific, measurable target behaviors related to Zyprexa use. Resident 13 was admitted and later readmitted with diagnoses including Alzheimer's disease, schizophrenia, and cerebral infarction. The H&P stated the resident had no capacity to understand and make decisions, and the MDS showed the resident required extensive assistance with multiple activities of daily living. Resident 13 had orders for Zyprexa 10 mg at bedtime and 2.5 mg in the evening related to schizophrenia manifested by hallucinations, and the MAR directed staff to monitor manifested behavior hallucinations every shift. During record review and interview, the RN supervisor stated there were no hallucinations documented and she did not witness signs or symptoms of hallucinations for the resident. She also stated the term hallucinations was very general and not a specific targeted behavior for Zyprexa use, and that staff should have clarified with the psychiatric nurse practitioner what specific target behaviors to monitor. The psychiatric nurse practitioner stated Zyprexa was ordered because the resident's family reported the resident believed people were pulling her legs to prevent her from getting up from her wheelchair. She stated the clinical documentation should have reflected the resident's condition and monitored target behaviors accurately because a GDR was based on clinical evidence. The MDS coordinator and DON both stated target behaviors should be resident-specific and measurable, and the DON stated inaccurate data could delay treatment and lead to continued unnecessary medication use. The resident's care plan addressed psychotropic medication use for hallucinations, but the facility's documentation did not show specific, measurable target behaviors being monitored for the medication.
Delayed Care Plan for Stage II Sacrococcygeal Pressure Ulcer
Penalty
Summary
The facility failed to create a comprehensive person-centered care plan in a timely manner for a resident with a Stage II pressure ulcer on the sacrococcygeal area. The resident was readmitted with diagnoses including metabolic encephalopathy and a Stage II pressure ulcer of the sacral region. The Minimum Data Set dated 12/4/2025 indicated the resident had moderately impaired cognition and required varying levels of assistance with eating, personal hygiene, dressing, footwear, oral hygiene, and toileting hygiene. During interview and record review, the Registered Nurse Supervisor stated the resident was readmitted on 11/28/2025 with the Stage II pressure ulcer, but the care plan titled "Potential for Pressure Ulcer development/ skin breakdown," created on 11/28/2025, did not include interventions for the pressure ulcer upon admission. The RN Supervisor stated the sacrococcyx pressure ulcer was not addressed in the care plan until 12/8/2025. The DON stated that developing a comprehensive person-centered care plan promptly upon noticing concerns, rather than waiting 10 days, is crucial because the care plan is what staff follow. The facility policy and procedure for Skin and Wound Monitoring and Management stated nursing staff will identify and document the condition and pressure injury risk factors in the resident's clinical record and that the plan of care begins at admission with the initial care plan and continues throughout the assessment process.
Failure to Coordinate and Document Hospice Visits
Penalty
Summary
The facility failed to ensure appropriate coordination with the hospice provider for one resident who was admitted with diagnoses including atherosclerotic heart disease and phimosis. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS later indicated severely impaired cognition with extensive assistance needs for eating, oral hygiene, dressing, personal hygiene, toileting hygiene, showering, and footwear. The resident had an order to admit to hospice with an admitting diagnosis of atherosclerotic heart disease, and the hospice care plan directed the facility to work cooperatively with the hospice team to meet the resident’s spiritual, emotional, intellectual, physical, and social needs and to provide maximum comfort. Review of the hospice client calendar and sign-in/notes for December 2025 and January 2026 showed that scheduled hospice aide visits on 12/18/25, 12/22/2025, 12/25/2025, and 1/1/2026, as well as a hospice RN visit on 1/19/2026, did not match the corresponding visit records. There was no documentation that the missed visits were rescheduled, completed later, or otherwise accounted for. During interviews, the SSD stated her hospice coordination role was limited to inviting hospice to care planning meetings, while the RNS stated hospice coordination is generally handled by social services and nursing and that the missing visit documentation showed lack of coordination and oversight. The DON stated the facility is expected to coordinate with hospice, including monitoring scheduled visits and ensuring services are provided as arranged, and the hospice services agreement required complete documentation of all services and events and cooperative efforts between the facility and hospice provider.
Failure to Measure and Document a Stage II Pressure Injury Weekly
Penalty
Summary
The facility failed to measure and document one resident’s Stage II pressure injury on the sacrococcygeal area at least weekly after admission. The resident was admitted with diagnoses including chronic kidney disease, anemia, and protein calorie malnutrition. The MDS dated 12/15/2025 indicated the resident’s cognitive skills for daily decision-making were intact, and that the resident needed set-up assistance with eating and oral hygiene, substantial assistance with personal hygiene, and was dependent on staff for toileting hygiene and showering. The MDS also indicated the resident was at risk for pressure injuries and had one unhealed Stage II pressure injury present on admission. The admission record documented the Stage II pressure injury in the sacrococcygeal area as measuring 4 cm by 3 cm with 0 depth, 100 percent granulation tissue, and light serosanguinous exudate. During interview and record review, the LVN confirmed that the only wound measurement was completed on admission and that, as of 28 days later, the pressure injury had not been measured to monitor progress. The LVN stated the wound should be measured and described at least weekly, and the DON also stated pressure injuries need to be measured minimally on a weekly basis to track progress. The facility policy titled Skin and Wound Monitoring and Management stated a licensed nurse will assess and evaluate each area of alteration at least weekly, including measuring the skin injury.
Missing Dentures Not Replaced or Referred for Dental Visit
Penalty
Summary
Failure to provide routine and emergency dental care occurred for Resident 15, who was admitted with diagnoses including dysphagia, breast cancer, and dementia. The resident’s H&P indicated she had no capacity to understand and make decisions. Her MDS showed she required assistance with multiple activities of daily living, including eating with supervision or touching assistance. During observation, Resident 15 had no natural teeth and no dentures at the bedside. She stated she did not know where her dentures were, said she had come to the facility with both upper and lower dentures, and reported that she had asked staff for help locating them but had not been updated on their status. She also stated she had discomfort while trying to eat or chew food because of the missing dentures and felt embarrassed when speaking to others without teeth. Record review showed her belongings list documented dentures on initial admission, but no dentures on readmission from the hospital. The RNS stated the dentures were lost during hospitalization and that Social Services should have been notified for replacement. The SSD stated she was not aware the dentures were missing, believed the resident still had them, and said the resident should have been seen by a dentist within three days. The DON stated Social Services should have arranged a dental visit to replace the missing dentures as soon as possible, and that nursing staff should have communicated the issue to Social Services.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure safe and appropriate discharge planning for a resident 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. The resident had complex medical conditions, including end-stage chronic kidney disease requiring dialysis, diabetes mellitus, dementia with fluctuating decision-making capacity, anxiety, and multiple healing fractures. The resident was dependent on nursing staff for activities of daily living such as toileting, showering, dressing, and transferring. Despite these needs, the facility initiated discharge orders to an assisted living facility without confirming the facility's ability to provide the necessary care or even verifying the correct facility name and location. Interviews and record reviews revealed that the receiving facility was not expecting the resident, was located in a different city, and typically only accepted independent, ambulatory residents without dementia. The Social Services Director was unable to locate the intended facility online and, upon contacting the administrator of the facility, discovered confusion regarding the resident's identity and admission. The discharge was ultimately delayed after it was determined that the transfer would not be safe or appropriate, and the discharge order was discontinued.
Failure to Inform Resident of Financial Obligations Prior to Discharge
Penalty
Summary
The facility failed to inform a resident that their insurance would not cover the cost of a board and care facility prior to discharge. The resident, who was admitted with diagnoses including hypertension and repeated falls and required supervision or assistance with hygiene, was able to make their own decisions. Prior to discharge, the resident specifically asked the social service staff if their insurance would pay for the board and care facility, and was incorrectly told that it would. Upon arrival at the new facility, the resident learned that their social security check would be used to pay for their stay, resulting in a share of cost that the resident was not prepared for. The Social Service Director acknowledged that she did not explain the financial obligations to the resident before discharge and recognized that the resident had the right to be informed. The Director of Nursing confirmed that residents should be informed in writing about payment expectations before discharge or transfer. The resident reported experiencing stress and anxiety due to the unexpected financial burden and stated that they would have preferred to be informed beforehand to make an informed decision. The facility's policy requires that appropriate information be communicated to the receiving provider, but this was not followed in this case.
Inconsistent Portion Sizes Lead to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion sizes, which resulted in 46 out of 81 residents on regular texture diets receiving incorrect portions of meatloaf. The menu specified a 3-ounce portion of meatloaf, but during an observation, it was found that the portions varied, with some pieces weighing as little as 2.5 ounces. This discrepancy was confirmed by a staff member who initially believed the portion size to be 2 ounces and adjusted the portions due to resident complaints about small sizes. However, upon checking the menu spreadsheet, the staff member acknowledged the correct portion size was indeed 3 ounces. Interviews with the Dietary Supervisor and Registered Dietitian highlighted the importance of following the menu spreadsheet to ensure residents receive adequate nutrition. The facility's standardized recipe and policies also emphasized the need for accurate portion control using appropriate equipment. The failure to provide consistent portion sizes had the potential to result in decreased nutrient intake and unintended weight loss among residents.
Deficiency in Food Preparation and Flavor
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, as observed during a survey. Specifically, the buttered carrots lacked butter flavor, and the mashed potatoes were bland and tasteless. This deficiency was identified through observations, interviews, and record reviews, indicating that the facility did not adhere to its policy of ensuring food is palatable and attractive. The Dietary Supervisor and Registered Dietitian confirmed during a test tray evaluation that the food did not meet flavor expectations, suggesting that the cook may not have followed the standardized recipes. The deficiency affected multiple residents, including those with specific dietary needs and medical conditions. Resident 42, who has chronic kidney disease, COPD, and protein-calorie malnutrition, reported that the food was bland. Resident 82, diagnosed with dysphagia and protein-calorie malnutrition, described the food as horrible. Resident 78, with chronic systolic heart failure and acute respiratory failure, stated the food was like poison, and Resident 27, with dysphagia and hypertension, also found the food unsatisfactory. These residents required various levels of assistance with eating and had specific dietary orders, such as no added salt and different texture modifications. The facility's policies and procedures for food preparation, dated July 19, 2024, required that food be prepared to conserve nutritive value, flavor, and appearance, using approved and standardized recipes. However, the facility's failure to adhere to these procedures resulted in poorly prepared food being served to residents. The standardized recipes for buttered carrots and mashed potatoes included specific ingredients and preparation methods, but the lack of flavor in the served food indicated a deviation from these guidelines. The Dietary Supervisor acknowledged that residents might not eat the food if it was not flavorful, which could lead to dissatisfaction and potential nutritional issues.
Failure to Prepare Puree Diets Correctly
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree level 4 diet. During an observation, it was noted that the puree meatloaf could not hold its shape, and the puree carrots were watery, which did not meet the required consistency for a puree diet. The dietary supervisor and registered dietitian confirmed that the puree meatloaf was spread out on the plate and the puree carrots had liquid seeping from them, which is inconsistent with the diet manual's definition of a puree diet. The puree diet is intended for residents with dysphagia and those without teeth, and it requires the food to be lump-free, not firm or sticky, and to hold its shape on the plate without liquids separating from the food. The facility's diet manual and recipes for puree foods, such as meatloaf and buttered carrots, were reviewed. The manual specifies that the puree diet should be prepared to a pudding-like consistency, with no lumps or liquid separation, to prevent aspiration and ensure the food is easily swallowed. However, the puree meatloaf and carrots did not meet these standards, as observed during the test tray evaluation. The registered dietitian highlighted the potential risk of aspiration for residents with difficulty swallowing if the food is not prepared correctly. The facility's recipes for puree foods were also reviewed, indicating specific instructions for achieving the correct texture, but these were not followed, leading to the deficiency.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Staff did not properly label food products, including Jello and dry potatoes, and failed to label residents' food from outside with the resident's name. This lack of labeling could lead to cross-contamination and incorrect diets being served to residents. Additionally, three dented cans were stored with non-dented cans, posing a risk of botulism, and various kitchen utensils and equipment were found to be chipped, cracked, or rusted, which could result in physical contamination of food. The kitchen equipment and food preparation surfaces were not adequately cleaned and sanitized. Observations revealed that the clean area for storing pots and pans had crumbs and food particles, pans had food residue, and the toaster and microwave had food splatter and residue. The tray-line top was rusted and dirty, and the resident's freezer temperature was not monitored, which could lead to food spoilage. Furthermore, staff did not perform hand hygiene appropriately, as they were observed touching garbage covers and picking up items from the floor without washing their hands before handling food. Food temperatures were not checked prior to tray-line service, and the mashed potatoes in the steamtable were found to be at 125 degrees Fahrenheit, below the required holding temperature of 140 degrees Fahrenheit. This failure to monitor and maintain proper food temperatures could result in serving undercooked or cold food to residents. The facility's policies and procedures were not followed, as evidenced by the lack of temperature logs and the improper handling and storage of food items, which could lead to foodborne illnesses among the residents.
Improper Garbage Disposal Leads to Potential Health Risks
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on 11/12/2024, when two dumpsters were found overflowing with trash, preventing the lids from closing. This was confirmed during an observation and interview with the Dietary Supervisor, who acknowledged that staff disposed of all food trash in these dumpsters. The overflowing trash and open lids were identified as a potential attractant for pests and rodents, which could carry diseases and pose a risk to the residents. Further observation and interview with the Environmental Services Director revealed that the trash vendor typically collected the trash once a day, but was delayed due to a holiday. The Environmental Services Director confirmed that the overflowing dumpsters and inability to close the lids were not acceptable, as they could attract flies and create an unpleasant environment. The facility's Policies and Procedures, as well as the Food Code 2022, emphasize the importance of proper garbage disposal to prevent nuisances and potential contamination, which were not adhered to in this instance.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) while providing direct care to a resident on enhanced barrier precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) was seen tending to a resident's care without wearing the required PPE, specifically a gown, while only wearing gloves. The CNA adjusted the resident's blanket and then left the room without performing hand hygiene, despite signage indicating the need for PPE due to the resident's EBP status. The resident in question was admitted with multiple diagnoses, including metabolic encephalopathy, a gastrostomy tube (G-Tube), type 2 diabetes mellitus, and hypertension. The resident was assessed as moderately impaired in cognitive skills and dependent on assistance for mobility and self-care. The facility's order summary report indicated that enhanced barrier precautions were necessary for the resident due to the presence of a G-Tube, requiring PPE for high-contact care activities. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the requirement for PPE to prevent the spread of infections. The facility's policy on infection prevention and control outlined the need for gown and gloves during high-contact activities, especially for residents with medical devices like G-Tubes. The failure to adhere to these guidelines posed a risk of infection transmission within the facility.
Failure to Notify Staff of Resident's Decreased Ankle Mobility
Penalty
Summary
The facility failed to ensure timely notification of nursing staff and a physician when a resident exhibited decreased range of motion (ROM) in both ankles. This deficiency was identified through observation, interviews, and record reviews. The resident, who was admitted with diagnoses including depression, Parkinson's Disease, and prostate cancer, initially had no ROM limitations according to assessments conducted in August. However, by November, a Joint Mobility Assessment revealed minimum ROM limitations in the resident's bilateral ankles. The resident's care plan, which was updated in November, included interventions for the newly identified bilateral ankle limitations, but there was a delay in notifying the appropriate medical personnel. A Restorative Nursing Assistant (RNA) noticed increased stiffness in the resident's right ankle in mid-October but only informed a physical therapist who no longer worked at the facility. The RNA did not report the change to nursing staff, which was against the facility's policy requiring immediate notification of any change in a resident's condition. Interviews with the Director of Rehab and the Director of Staff Development confirmed that the RNA should have reported the decline in ROM to both rehab and nursing staff immediately. The facility's policy and job descriptions clearly state the responsibility of RNAs to report changes in residents' conditions to ensure timely evaluation and intervention. The delay in communication resulted in a postponement of necessary evaluations and interventions for the resident's condition.
Failure to Follow Up on Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to follow up on a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for a resident diagnosed with depression, Parkinson's Disease, and prostate cancer. The resident was admitted with a positive PASRR Level 1 screening indicating the need for a Level 2 evaluation due to a serious mental illness. However, the facility did not respond to multiple attempts to complete the Level 2 evaluation, resulting in the case being closed without the necessary assessment. The Director of Nursing (DON) was unaware of the attempts to contact the facility for the evaluation until the review. The Notice of Attempted Evaluation letter was uploaded into the electronic medical record, but the DON was not informed, leading to a failure to complete a new Level 1 screening to reopen the case. This oversight had the potential to delay services for the resident, as the Level 2 PASRR is crucial for ensuring all resident needs are met.
Failure to Administer Insulin According to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident with type 2 diabetes and chronic kidney disease received her insulin as ordered by the physician. The resident's care plan included interventions for diabetes management, specifically receiving diabetes medications as prescribed. However, a review of the Medication Administration Record (MAR) for October and November 2024 revealed that Insulin Glargine was administered on multiple occasions when the resident's blood sugar levels were below the physician-ordered threshold of 150 mg/dL. This administration occurred despite the physician's explicit instructions to hold the insulin if the blood sugar was below this level. During an interview, the Director of Nursing (DON) acknowledged that the insulin was given contrary to the physician's parameters, which posed a risk for hypoglycemia. The DON emphasized the importance of adhering to physician orders to prevent adverse effects, particularly since insulin is a high-risk medication. The facility's policy required nurses to administer medication according to the written orders of the attending physician, which was not followed in this case, leading to the deficiency.
Inadequate Pain Management Assessment and Monitoring
Penalty
Summary
The facility failed to accurately assess and monitor the effectiveness of pain management for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including depression, Parkinson's Disease, and prostate cancer, was prescribed various pain medications such as Percocet, Tylenol, Cyclobenzaprine, and Gabapentin. Despite these prescriptions, the resident's care plan indicated that the pain was not relieved by the current medications, and the resident frequently reported experiencing severe pain. The Medication Administration Record (MAR) for the resident showed inconsistencies in pain assessment and documentation. The MAR indicated that the effectiveness of Tylenol was often marked as unknown, and the resident's pain level was consistently documented as 0, despite the resident reporting significant pain. Additionally, there was no record of reevaluation for pain after administering Percocet, and the pain characteristics were not monitored as required by the care plan. Interviews with the resident and staff revealed that the resident frequently experienced severe pain and felt that the facility was not adequately addressing his pain management needs. The Director of Staff Development acknowledged that the nurses were not documenting a full pain assessment, and there was a lack of reevaluation of pain after medication administration. The facility's policy required documentation of the response to pain medication and contacting the physician if the pain management program was ineffective, which was not consistently followed in this case.
Failure to Follow Insulin Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's ordered parameters for insulin administration. The resident, who was admitted with diagnoses of type 2 diabetes and chronic kidney disease, had specific orders for Insulin Glargine to be held if blood sugar levels were below 150 mg/dL. However, the medication was administered on multiple occasions when the resident's blood sugar levels were below this threshold, as documented in the Medication Administration Record (MAR) for October and November 2024. The Director of Nursing (DON) acknowledged that the insulin was given contrary to the physician's orders, which posed a risk for hypoglycemia and other adverse effects. The facility's policy required nurses to administer medication according to the physician's written orders, emphasizing the importance of following these parameters to prevent potential harm. Despite this policy, the insulin was administered incorrectly, highlighting a significant medication error in the care of the resident.
Failure to Provide Timely Restorative Nursing Aide Program
Penalty
Summary
The facility failed to provide a Restorative Nursing Aide (RNA) program to a resident who was not discharged home as initially planned and continued to stay in the facility. The resident, who had a history of falling and weakness, was admitted with intact cognition and required partial to moderate assistance for activities of daily living (ADLs). Despite the resident's care plan indicating a goal to increase their level of function in ADLs, RNA services were not initiated until 2/19/2024, even though the resident remained in the facility from 2/6/2024 to 3/6/2024. The delay in providing RNA services was due to the initial discharge plan, which recommended home health services and did not indicate the need for restorative programs. However, the resident's physician requested RNA services on 2/17/2024, and the services were started on 2/19/2024. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the lack of RNA services could affect the resident's range of motion and strength. The facility's policy indicated that residents should be assessed for physical/occupational therapy or maintenance ROM programs to achieve or maintain their level of self-care or mobility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater Skilled Nursing Center | 0.6 mi | ★★★★★ | 21 | 0 |
| Pacific Palms Healthcare | 0.7 mi | ★★★★★ | 41 | 0 |
| Broadway By The Sea | 0.7 mi | ★★★★★ | 26 | 0 |
| Marlora Post Acute Rehab Hosp | 0.8 mi | ★★★★★ | 31 | 1 |
| Shoreline Healthcare Center | 0.9 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.