Other·January 25, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of The Department of Public Health during the investigation of a Facility Reported Incident (ERI). FRI Number: CA00552299 Representing the Department of Public Health: Surveyor ID: 38550 RN, HFEN The inspection was limited to the specific FRI investigated and does not represent a full inspection of the facility. One deficiency was issued for FRI Number: CA00552299

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and procedures to implement safety measures and a resident's plan of care to ensure a resident was supervised with the use of assistive devices to prevent falls and injury for one of three sampled residents (Resident 1). Resident 1, who was at risk and had a history of falls, had an order for a pad bed alarm (a pad used for fall prevention that alarms when the resident stands up), but the facility's staff were aware that the resident knew how to turn the alarm off and failed to provide another form of intervention to prevent Resident 1 from falling. This deficient practice resulted in Resident 1 falling and sustaining a fracture (broken bone) to the right humeral neck (shoulder), requiring a transfer to a general acute care hospital (GACH) for further evaluation and treatment that lead to a decline in Resident 1's rehabilitation progress. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Record of Admission Face Sheet indicated the resident was admitted to the facility on August 3, 2017. The resident's diagnoses included an intertrochanteric fracture of the left femur (a broken hip bone) with rehabilitation to be conducted, a history of falling, abnormal gait (walking) and mobility, benign prostatic hyperplasia (an increase in size of the prostate that can cause symptoms such as frequent urination), generalized muscle weakness, and dementia (loss of memory and other mental abilities severe enough to interfere with daily life). A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated August 10, 2017, indicated a Brief Interview for Mental Status (BIMS) score of 15 (13-15=no mental impairment), which indicated that Resident 1 did not have any problems with memory and cognition (thought process). The MDS indicated Resident 1 required an extensive assistance of a two-person physical assist for bed mobility, transferring, and toilet use. According to the MDS, Resident 1 was not steady and required staff assistance for stability with walking, transferring when moving from a seated to standing position and for moving on/off of the toilet. The MDS indicated Resident 1 was receiving a diuretic medication (causes increase urination) daily. A review of Resident 1's History and Physical form, dated August 7, 2017, indicated the resident had fluctuating capacity to understand and make decisions. The resident's admission plan of care included rehabilitation and that the resident was a good candidate for rehabilitation. A review of Resident 1's Admission Assessment, dated August 3, 2017, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident was admitted to the facility from GACH 1 after a fall at home that resulted in a left hip fracture. The resident was identified as a high fall risk, had some confusion, and was admitted to the facility for physical therapy ([P/T] used to improve a patient's quality of life through examination, diagnosis, prognosis, physical intervention, and patient education) and occupational therapy ([OT] use of assessment and intervention to develop, recover, or maintain the meaningful activities, or occupations, of individuals, groups, or communities) rehabilitation. A review of Resident 1's Fall Risk Evaluation form, dated August 3, 2017, indicated Resident 1 had a fall assessment score of 21 (10 and above=high fall risk). The Fall Risk Assessment also indicated Resident 1 was legally blind. A review of Resident 1's care plan, dated August 4, 2017 and titled, "Falls," indicated the resident was at risk for falls and would be free from fall or injury. The staff's interventions included anticipating the resident's needs and keeping frequently used items within the resident's reach. A review of Resident 1's care plan, dated August 4, 2017 and titled, "Activities of Daily Living (ADL's)," indicated the resident required assistance with all ADLs. The staff's interventions included praising the resident when independence was attempted or done, encouraging independence with minor assistance and assisting the resident with toileting as needed. A review of another care, plan dated August 4, 2017 and titled, "Vascular Dementia," indicated the resident had altered thought processes and all the resident's needs would be met and anticipated within 90 days. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staff's interventions included closely monitoring the resident for safety and frequent visual checks. A review of Resident 1's Physician Orders, dated August 3, 2017, indicated the following: 1. Resident 1 was to have a sensor pad placed in the resident's bed and wheelchair for safety due to the resident having poor safety awareness. The staff were to monitor the functionality and placement of the alarm pads every shift. 2. Resident 1 was to be monitored every shift for attempts to get out of the bed or wheelchair unassisted. A review of Resident 1's Nursing Notes for the following days indicated: 1. On August 17, 2017 and at timed at 12:43 p.m., Resident 1 did not use the call light and made attempts of trying to get out of the bed and into the wheelchair without assistance. 2. On August 23, 2017 and timed at 1:55 p.m., Resident 1 transferred from the wheelchair and into the bed without assistance and without using the call light. The resident's wheelchair was observed unlocked, but the sensor pads were in place. A review of a Nurse's Note, dated September 10, 2017 and timed at 3:15 a.m., Resident 2 (Resident 1's roommate) could be heard calling out for help. When the staff entered Resident 1 and 2's room, Resident 1 was found on the floor and was assisted back to the bed. Resident 1 stated that he had fallen while attempting to stand up and use the restroom. The nurse's note indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE complained of pain (right shoulder) and was given Norco (a narcotic pain medication) at 5 a.m. An x-ray (a test used to take pictures of structures, such as bones, inside the body) was done at 4:50 a.m., which indicated Resident 1 had a right humeral neck (arm) fracture. Resident 1 was transported to the GACH via ambulance at 6:55 a.m. for further evaluation and treatment. A review of GACH 1's Emergency/Urgent Care documentation, dated September 10, 2017, indicated Resident 1 arrived to the GACH and reported right arm and shoulder pain. The GACH's X-ray indicated there was a right humeral neck fracture. A shoulder immobilizer (used to make immobile or immovable; fix in place; to prevent the use, activity, or movement of) was placed on the resident's arm and the resident was discharged back to the facility. A review of a nurse's note, dated September 10, 2017 and timed at 12:59 p.m., Resident 1 returned to the facility via ambulance with a right shoulder immobilizer intact. A review of an OT Progress Report, dated September 14, 201, without a time, indicated after the fall Resident 1 had a decline in functional levels due to the resident's right arm fracture. A review of Resident 1's PT Progress Report, dated September 18, 2017, without a time, indicated after falling, Resident 1's therapy goals had to be downgraded. According to both the PT and OT assessment reports, prior to the fall, Resident 1 had been making good progress in therapy. On October 4, 2017 at 11:08 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that floor mats were used for residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that frequently attempted to get out of bed unassisted, but stated Resident 1 did not have any floor mats. LVN 1 was unable to recall any instances of Resident 1 attempting to get out of bed unassisted. The LVN stated that on the day of the incident (September 10, 2017) he was on break, but could hear Resident 2 was yelling that someone was on the floor and needed help. LVN 1 stated when he entered the room, Resident 1 was found on the floor and complained of right shoulder pain. On October 4, 2017 at 11:42 a.m., during an interview, Resident 2 stated on the day of the incident (September 10, 2017), Resident 1 was heard getting out of the bed. Resident 1 was then heard yelling out and was seen on the floor. Resident 2 stated that the facility's bed alarms are usually loud and that Resident 1's bed alarm did not make any noise the night of the incident. Resident 2 stated he yelled out for help, and when no one came, he pressed the call light and the staff arrived to the room approximately two (2) minutes later. A review of Resident 2's MDS, dated September 4, 2017, indicated a BIMS score of 15 (13-15 no impairment), which indicated that Resident 2 did not have any problems with memory and/or cognition (thought process). On October 4, 2017 at 11:51 a.m., during an interview, PT 1 stated after Resident 1's fall, the resident had a setback in mobility and was not able to walk for two weeks. PT 1 stated that the resident was right hand dominant and due to the resident's right arm being fractured, the resident was off balance and unable to functionally walk. At 1:46 p.m., on October 4, 2017, during an interview, Certified Nursing Assistant 1 (CNA 1), who was the resident's primary care giver, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated Resident 1 frequently tried to get out of the bed and the wheelchair unassisted. On November 21, 2017 at 10 a.m., during an interview, Resident 1 stated he fell and broke his arm after attempting to stand near the side of the bed. The resident stated he did not use the call light because he was able to walk, the resident stated that the staff did not ask him to use the call light for assistance until after he fell. Resident 1 stated he had problems with balance and had a previous fall at home. On November 21, 2017 at 10:05 a.m., during an interview, Certified Nursing Assistant (CNA 1) stated Resident 1 knew how to turn off the pad alarm. At 10:15 a.m., on November 21, 201, during an interview, the maintenance supervisor (MS) stated if a resident knew how to turn off the bed alarm, the facility should have ordered bed alarms that did not have a turn off button. The MS stated the facility did not have any bed alarms without a turn off button. On November 21, 2017 at 10:25 a.m., during an interview, the Assistant Director of Nursing (ADON) stated upon admission to the facility, Resident 1 was assessed as a high fall risk. The ADON stated fall prevention measures for residents included the placement of a sensor pad bed alarms. A review of the facility's undated policy and procedure titled, "Personal Alarms," indicated for residents at risk for falls, safety measures such as bed alarms and floor mats would be implemented. The policy indicated that nursing staff would check the functionality of the safety devices every shift and CNAs were to report any malfunctioning or refusals to use the safety device. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056125 (X3) DATE SURVEY COMPLETED 12/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMITOS BELMONT HEALTH AND REHABILITATION 3901 E 4th St Long Beach, CA 90814 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policy and procedure titled, "Fall," indicated the facility would implement preventative interventions and assess the effectiveness of safety interventions for residents at risk for fall or injury. Residents were considered high fall risk if they had conditions such as dementia, problems with cognition and/or if they had a history of falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMJL11 Facility ID: CA940000062 If continuation sheet 9 of 9