Health inspection·December 13, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During 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.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to Stage 5 chronic kidney disease (the final stage where kidneys fail requiring dialysis[a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) , diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) with anxiety (emotion characterized by feelings of tension, worried thoughts ) and multiple healing broken bone to the back. During a review of Resident 1's History and Physical (H&P), dated 8/1/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/20/2025, the MDS indicated Resident 1 was dependent on nursing staff for toileting, showering, dressing, putting on and taking off footwear, personal hygiene and transferring. During a concurrent interview and record review on 12/13/2025 at 11:13 a.m. with the Social Services Director (SSD), Resident 1's Physician Orders dated 12/12/2025 were reviewed. The orders indicated that Resident 1 was scheduled for discharge on [DATE] at 2:00 p.m. to an assisted living facility (a housing option that provides personal care and support services to residents who need help with daily tasks but do not require 24/7 medical care). The SSD confirmed that Resident 1 was being discharged to an assisted living facility and stated that the facility used a placement referral to make arrangements for this discharge. During a telephone interview on 12/13/2025 at 11:44 a.m. with the Administrator (ADM) of the assisted living facility, the ADM stated that the name of her facility was different from the one listed in Resident 1's Physician Orders. The ADM further stated that her facility was located in a different city and was an independent living facility that accepts residents who were very independent, require minimal care, and are ambulatory. The ADM explained that the facility typically does not accept residents with dementia. The ADM stated she had never heard of the facility name listed in the Physician Orders and was not expecting any admission on [DATE]. Additionally, the ADM confirmed she was not aware of any resident by the name of Resident 1. During an interview on 12/13/2025 at 1:09 p.m. with the Social Services Director (SSD), the SSD stated that typically, the assisted living facility visits their facility and communicates with nursing staff regarding residents' medications and Page 1 of 2 056125 056125 12/13/2025 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses. The SSD stated she spoke with the assisted living facility's Administrator on 12/12/2025 regarding transportation arrangements. When asked to search for the assisted living facility online, the SSD stated she was unable to locate the facility. The SSD then contacted the Administrator of the assisted living facility, who explained that she had another resident scheduled for admission and initially thought Resident 1 was that individual with a similar name. The Administrator further stated she was confused about the situation and was not expecting Resident 1's admission. The SSD stated Resident 1 would not be discharged to the assisted living facility because it was not considered safe, and the discharge would be delayed.During a record review of Resident 1's Physician Orders, dated 12/13/2025 at 2:34 p.m., Resident 1 had an order to discontinue the discharge order to assisted living.During a review of the facility's policy and procedure (P&P), titled Criteria for Transfer and Discharge, date revised 4/2025, It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. 056125 Page 2 of 2