Other·May 3, 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 of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00615161 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 37393 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. On March 26, 2019, at 4:12 p.m., an Immediate Jeopardy (IJ) was declared under F 689 and the facility's Administrator and Director of Nursing (DON) were notified. The facility submitted an acceptable plan of action. The IJ was abated on March 27, 2019, at 4:48 p.m., and the Administrator was informed, after the team confirmed the facility's plan of action was implemented.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/03/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 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: NOBZ11 Facility ID: CA940000062 If continuation sheet 1 of 15 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 04/05/2019 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 §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure assisted devices and supervision was provided to prevent falls and injuries during physical therapy for one of four sampled residents (Resident 1). Resident 1, who was overweight (weighing 244 pounds) was admitted to the facility for rehabilitation after undergoing bilateral knee surgery, was assessed as requiring a two-person extensive assist with transfer and locomotion but was not provided with adequate supervision and/or assistive devices to prevent falls and injury. This deficient practice resulted in Resident 1, who was status-post bilateral knee surgery (11/8/18) and required assistance during stair climbing training, was being trained in the facility's poorly lit basement stairwell without a gait belt (device used to transfer people from one position to another or from one thing to another) and a one-person assist, fell and sustained a right knee fracture (broken bone) and a left knee tendon rupture (tendon separates in whole or in part from the tissue it is attached to). Resident 1 required a transfer to a general acute care hospital (GACH) and two days later, on 12/3/19, underwent two additional knee surgeries to repair the injuries after the fall. The facility staff continued to stair-train other residents in the basement after Resident 1 fell. On 3/26/19 at 4:12 p.m., an Immediate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 2 of 15 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 04/05/2019 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 Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ. The IJ was lifted and the POA was accepted on 3/27/19 at 4:48 p.m., after the team verified the POA which included the following: 1. To assure safety of the residents, all residents will be properly assessed by the physical therapy department prior to participation in stair training to ensure the resident has the capacity to be trained. 2. The director of rehabilitation (DOR) provided an in-service for the rehab department staff on 12/14/18, regarding patient safety while stair training in the stairway that leads down to the facility's basement. 3. The facility implemented a new policy that requires two therapists with a patient while being stair trained in the stairwell. 4. Ongoing in-services will be provided by the DOR as needed, but at least annually. 5. The DOR will monitor the rehab department to ensure safety of individual residents who participate in stair training in the basement. 6. A new set of mobile training stairs was purchased and is being used in the rehab gym as well. 7. A telephone was installed on 3/27/19 at the bottom of the basement stairs, which will allow any staff member who is providing stair training with residents to make a telephone call, in the event of an emergency. 8. The facility will provide a standardized training in writing regarding patient safety in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 3 of 15 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 04/05/2019 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 stairwell, which will be especially helpful for per-diem, on-call, weekend and registry therapist staff who are not as familiar with the facility. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 11/11/18. Resident 1's diagnoses included bilateral total knee replacement (a surgical procedure to replace the weightbearing surfaces of the knee joint to relieve pain and disability), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), difficulty walking, hypertension (high blood pressure), and Type 2 diabetes (a condition that affects the way the body metabolizes glucose [sugar]). A review of Resident 1's History and Physical (H/P), dated 11/12/18, indicated the resident had the capacity to understand, make decisions and be understood. According to the H/P, Resident 1 had an allergy to opiates (narcotic drugs used to treat pain) and was status-post bilateral knee replacement surgery on 11/8/18 with bilateral knee pain. According to the H/P, Resident 1 weighed 244 pounds. A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/18/18, indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and able to understand others. According to the MDS, Resident 1 was assessed as requiring an extensive two-person physical assistance with bed mobility, transferring, locomotion on and off the unit, and extensive assistance with personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 4 of 15 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 04/05/2019 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 MDS indicated under Section G 300, balance during transfers and walking, that Resident 1 was not steady and was only able to stabilize with staff's assistance. The MDS under Section G 400, functional limitation in range of motion (ROM), that Resident 1 was assessed with impairment on both sides of her lower extremities and required a use of a wheelchair for mobility. A review of Resident 1's care plan initiated on 11/12/18, identified a problem with falls and/or injury. The goal indicated that Resident 1 would be free from fall and/or injuries. The staff's interventions included to keep close observation of the resident to minimize potential for falls during activity and to anticipate resident needs. A review of Resident 1's care plan initiated on 11/12/18, identified a problem with degenerative joint disease [DJD] with a risk of joint pain, swelling, stiffness secondary to bilateral knee total joint replacement, with the potential for contractures (define) or limitations of extremities. The goal indicated Resident 1 will not have unresolved pain, joint swelling and joint stiffness daily. The staff's approach plan included gentle handling during care, assess for signs of joint swelling and pain and address in a timely manner. Provide gentle ROM during ADLs as tolerated, provide Physical therapy as ordered. A review of a physician's order, dated 11/12/18 indicated an order for a physical therapy (PT) evaluation for Resident 1 and treatment six (6) times a week that included Therex (therapeutic exercises used for the purpose of restoring strength, endurance, ROM and flexibility where loss or restricted as a result of a specific disease or injury and has resulted in a functional limitation) and gait training (help FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 5 of 15 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 04/05/2019 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 improve the ability to stand and walk). A review of the PT's evaluation and plan of treatment, dated 11/12/18-1/6/19, indicated aftercare following the bilateral joint replacement surgery with an onset date of 11/8/18 with the presence of bilateral artificial knee joints, and rheumatoid arthritis. The plan of treatment short-term goals included Resident 1 would safely ascend/descend (climb up/down) one (1) stair using handrails bilaterally and tactile cues for proper sequencing, for task segmentation, for correct use of an assistive device, and for correct hand foot placement with the ability to right self to achieve /maintain balance with a target date of 11/25/18. The plan's long-term goals indicated Resident 1 will safely ascend/descend less than fifteen (15) stair using handrails bilaterally and tactile cues for proper sequencing, for task segmentation, for correct use of an assistive device, and for correct hand foot placement with ability to right self to achieve /maintain balance with a target date of 1/6/19. The PT evaluation and plan of treatment indicated Resident 1's current level of function and underlying impairment of pain 10 out of ten on the pain scale (10 being the worse pain) that was described as sharp and shooting upon movement. According to the PT Assessment, Resident 1 experienced pain at rest that was constant pain at 3 out of ten, which the resident described as gnawing and heavy in the right and left knees. The PT concluded that Resident 1's pain limits functional activities. A review of the modified barthel index (a scale used to measure one's performance in ADLs which assesses a resident's functional independence), dated 11/27/18 indicated Resident 1 had a score of 50 out of 100 indicating a moderate dependency level. The scale indicated that Resident 1 was unable to perform the task of stair climbing and required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 6 of 15 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 04/05/2019 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 substantial help with ambulation. A review of a PT's treatment encounter note, dated 11/29/18, written by a physical therapy assistant (PTA 4), and co-signed by the physical therapist (PT 1) on 12/2/18 and timed at 7:57 a.m., indicated treatment as planned patient (Resident 1) transferred to wheelchair and stated right arm was flared up and feels pain in the left shoulder. Nursing administered pain medication. Patient (Resident 1) required step training 1-inch step three times with stand by assist, 4inch steps three times with contact guard assist, 6-inch steps three times to assimilate patient's (Resident 1's) home environment with contact guard assist and minimum cues for sequencing. Resident transferred into wheelchair with contact guard assist (one or two hands on one's body but provides no other assistance to perform the task). A review of Resident 1's PT treatment encounter note, dated 11/30/18, written by PTA 4, and co-signed by PT 1 on 12/2/18 at 7:57 a.m., indicated "treatment emphasis included gait training, step training and therapeutic activities. Patient (Resident 1) required several seated therapeutic rests today after every functional task in general during treatment due to the patient (Resident 1) indicating her right arm had flared up and especially left shoulder, but was very determined to attempt 6-inch stairs in the basement today. Patient (Resident 1) was able to ascend and descend three steps three times with three therapeutic rests of 2-3 minutes due to the height of the step and patient's present diagnosis of bilateral total knee replacements (TKR). Patient used nonreciprocating sequencing single rail left ascending. Gait training initiated after steps and seated rest. Patient completed therapy in good spirits after being able to complete FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 7 of 15 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 04/05/2019 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 therapy especially step training. Patient requires further training with steps, patient will have to be able to ascend approximately twenty steps to enter residence. Presently patient moves somewhat labored antalgic gait (a gait that develops as a way to avoid pain while walking) noted, but also requires several therapeutic rests due to patient's decreased functional endurance and stature, very pleasant and hard worker with therapy. " A review of a Situation, Background, Assessment and Recommendation ([SBAR] internal communication form), dated 12/1/18 and timed at 2:30 p.m., indicated Resident 1 had an assisted fall while going up and down the stairs in the stairwell during physical therapy training. A review of a nurses' note, dated 12/1/18 and timed at 5:22 p.m., written by a Licensed Vocational Nurse 1 (LVN 1) indicated Resident (Resident 1) with family member (FM1) at the bedside complaining of knee pain status-post assisted fall to the ground. Administered Zanaflex (tizanidine) 4 milligrams (mg) (muscle relaxant for muscle spasms) with relief. Administered all medications and tolerated well. Resident awaiting STAT (immediate) xray. The note indicated the resident (Resident 1) was alert and oriented, verbally responsive and able to make needs known. The note indicated "to continue with PT/ OT services as tolerated; provide assistance with bathing, dressing, and transferring and keep clean at all times." The resident respirations were noted as even and unlabored with no shortness of breath (SOB). Call light within reach and will continue to monitor. All needs met and attended, no signs or symptoms of bleeding, bruising, or skin discoloration due to aspirin use. A review of the nurses' note, dated 12/1/18 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 8 of 15 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 04/05/2019 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 timed at 7:21 p.m., written by LVN 1 indicated x-rays completed x-ray at 6:35 p.m., awaiting results. A review of the right knee x-ray results, dated 12/1/18 and timed at 7:58 p.m., indicated status-post right total knee arthroplasty, a periprosthetic knee fracture involving the inferior right patella with significant fracture fragments with proximal migration of the majority of the patella (knee bone). This x-ray was compared to the prior x-ray, dated 11/27/18, which indicated there was no periprosthetic fracture and the knee was anatomically aligned, before the fall incident. A review of a PT treatment encounter note, dated 12/1/18 and timed at 8:11 p.m., written by a physical therapy assistant (PTA 3) and cosigned by PT 1 on 12/2/18 and timed at 7:57 a.m., indicated Resident 1 was pre-medicated without complaint of pain and taken to the basement for stair training. According to the note, Resident 1 was able to ascend three steps up and down using left handrail with contact guard assist and instructions to adjust velocity and cues to clear foot every step to facilitate safety. The resident was able to take two steps using right lower extremity, but on the third step, decided to take a step using left lower extremity with instructions to use right lower extremity. Resident 1's left knee buckled and the resident immediately started yelling. Stayed with patient and called for help, nursing and rehab staff transferred patient onto wheelchair, provided cold packs on both knees, and transferred patient using sliding board post pain medication administration. A review of the nurses' note, dated 12/1/18 and timed at 10:36 p.m., indicated Resident 1's xray results were abnormal for an acute fracture of inferior right patella (knee) with significant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 9 of 15 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 04/05/2019 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 distraction of the fracture fragment. The note indicated that the primary physician and the orthopedic surgeon were notified, received new orders for an immobilizer (medical device applied to a part of the body to keep from moving) and apply ice to the area four times a day. No flexion exercise to the right knee. On 3/18/19 at 10:19 a.m., during an interview, PT 2 stated that the basement stairs are typically used for high level residents. PT 2 stated that the resident walks up or down the stairs two to three at a time and then the resident would rest. PT 2 indicated that the stair training was used to mimic the surroundings once the resident was discharged from the facility and back at home. At 10:29 a.m., on 3/18/19, during a subsequent interview and concurrent observation of the basement stairs with the DOR, she stated that Resident 1's fall incident occurred over the weekend and that PTA 3 had called and reported what happened. The DOR stated that when a resident received stair training in the basement they have already had training using blocks before transitioning to the stairs. The DOR stated that the rehabilitation training stairs were damaged by the rainy weather because they were kept outside in the element and that a new set of training stairs were ordered in January 2019 and received in February 2019. The DOR stated that Resident 1 was trained in the basement stairwell for the first time a day prior to the fall by two physical therapy staff members, and it was the resident's first time working with PTA 3. The DOR stated that PTA 3 was a part time staff member, because of another job obligation during the week. On 3/18/19 at 10:32 a.m., during an interview the DOR was questioned regarding ensuring safety for residents during stair training and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 10 of 15 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 04/05/2019 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 DOR replied that during training a gait belt should be used during training. The DOR attempted to use her personal cell phone to make a telephone call from the basement and the call was unsuccessful. The DOR stated that due to the fall incident and PTA 3 being unable to call for help, the facility implemented a new protocol for two physical therapy staff members to assist a resident during stair training for safety. On 3/18/19 at 10:36 a.m., the Maintenance director (MTA) stated that there was a phone in his office located in the basement but that the office was usually locked to protect the equipment inside. At 10:39 a.m., on 3/18/19, the MTA measured the height of the basement stairs and stated that the height of the first stair was 8 inches and the other stairs going up were 7 inches. The MTA stated that the door at the top of the stairs remains locked for resident's safety and that the maintenance staff and charge nurses have a key to the door leading to the basement. The other staff use the elevator to get to the basement. On 3/20/19 at 3:42 p.m., during an interview, PTA 3 stated that she reviewed the stair training notes for Resident 1 for three days prior and was repeating the training from the day before. PTA 3 stated that it was her first time working with Resident 1 and she ensured that the resident received pain medication prior to the physical therapy. PTA 3 stated that she was not sure of the basement stair height, but had taken other residents to the basement for training before. PTA 3 stated that Resident 1 was descending the basement stairs using the left handrail and the resident was told to rest after three stairs was completed. PTA 3 stated that Resident 1 was excited and wanted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 11 of 15 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 04/05/2019 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 continue stair training, and on the fourth stair a loud crack noise was heard, and Resident 1 immediately yelled. PTA 3 stated Resident 1 was yelling in pain and that while being held she was guided, and the resident used her hands to sit on the stairs. PTA 3 stated that she was unsure if a gait belt was used because the resident was either contact guard assist or minimum assist. PTA 3 stated she tried to call the facility's front desk for help using her personal cell phone, but there was no service in the basement and the call was unsuccessful. PTA 3 stated she left Resident 1 and went and found a housekeeping staff member and told the person to go upstairs for help. PTA 3 stated that she waited with Resident 1 for a few minutes and that various staff members from the Physical therapy department responded (PTA 1 and PTA 2) came to the basement, but was unsure exactly who from the nursing department responded, because she does not work at the facility often. PTA 3 stated that emergency paramedics were not called and the physical therapy staff used linen sheets to pick up Resident 1 to place her in a wheelchair to take her back to her room. PTA 3 stated that she was traumatized by the incident and the nursing staff took over the resident's care. PTA 3 stated that she called the DOR and reported what happened. On 3/21/19 at 11:11 a.m., during an interview, Resident 1 stated that PTA 3 brought her to the basement for stair training on December 1, 2018 and that she had only climbed three stairs the day prior and it was with two other physical therapy staff members. Resident 1 stated she had concerns initially about the stair training because the therapist (PTA 3) did not use a gait belt and did not assist her physically at all during the training. Resident 1 stated that after going up three steps she needed to rest, but PTA 3 told her to continue. Resident 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 12 of 15 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 04/05/2019 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 PTA 3 was standing at the bottom of the stairway during the therapy looking at her telephone without any hands on technique with her. Resident 1 stated that she felt her right knee get weak and used her to left leg to stabilize and suddenly both legs collapsed and she fell on the stairs. She (Resident 1) stated she started crying and took a deep breath. Resident 1 stated that the handrails on the basement stairwell were too wide to hold both at the same and she was only able to hold on to one handrail during the training. Resident 1 stated that she felt an excruciating pain on both knees and her legs were pinned underneath her and she felt her heels touching her buttocks. Resident 1 stated that she screamed out and in pain because it was unbearable that it felt as if her surgical wounds had reopened. Resident 1 stated that PTA 3 was also started screaming and she had to yell at PTA3 to help pull her legs from underneath her while grasping onto the single rail unable to reach the other. Resident 1 stated that as soon as her legs were pulled from underneath her buttocks by PTA 3, she passed out from the horrible pain while clenching onto the handrail. Resident 1 stated that she awoke and felt the cold wall against her cheek and opened her eyes and observed PTA 3 attempting to use her personal cell phone to call for help and the calls did not go through. Resident 1 stated she waited on stairs until a few staff members along with FM1 came to the basement. Resident 1 stated that PTA 1 and PTA 2 placed a linen sheet under her armpits and under her legs to lifted her into the wheelchair and took her back to her room. Resident 1 stated she was administered synthetic opiate pain medication due to her allergies to opiates, which did not help the pain. Resident 1 stated that she asked the nursing staff to call emergency paramedics to be transferred to the GACH right away but that she was told to wait for her orthopedic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 13 of 15 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 04/05/2019 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 surgeon orders. Resident 1 stated an x-ray of her legs were taken at the facility four hours after the fall. Resident 1 stated that since the fall she has been unable to stand or walk, and fears that the fall may negatively impact her ability to walk again. Resident 1 stated that since the fall she has had a lot of emotional distress and depression with crying spells. Resident 1 stated she stayed at the facility a couple of days before being transferred to the GACH and once transferred she underwent surgery the following day (12/4/18). Resident 1 stated that since the fall she has had to receive two additional surgeries to repair the fracture and a ruptured tendon due to the fall. Resident 1 stated that the facility Administrator (ADM) offered her money after the fall incident, and that he kept pressuring her to sign a contract for the money. Resident 1 stated she wanted to focus on her recovery and refused to sign the contract. On 3/26/19 at 4:18 p.m., the DOR provided a list of four current residents who are currently receiving basement stair training. On 3/27/19 at 3:48 p.m., during an interview PTA 2 stated that he was called down to the basement by a nurse to assist with Resident 1. PTA 2 stated that when he arrived to the basement he saw Resident 1 and PTA 3 on the basement stairs. PTA 2 stated that it was suggested by a nurse to call emergency paramedics to remove Resident 1, but the he did not think it was necessary. PTA 2 stated with the help of PTA 1 and PTA 3, two linen sheets were used to wrap Resident 1's upper body and lower body to lift into the wheelchair. PTA 2 stated that he does not remember Resident 1 having a gait belt on her when he transferred her into the wheelchair. PTA 2 stated a nurse brought Resident 1's daughter down to the basement to comfort the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 14 of 15 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 04/05/2019 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 PTA 2 stated Resident 1 was escorted to her room and was left in the care of the nurses. PTA 2 stated he returned to assist with transferring Resident 1 into bed. On 3/27/19 at 4:14 p.m., during an interview in the presence of the DOR, Resident 2 stated that she had been admitted to the facility three times, and every time she has been a resident at the facility she received basement stair training at least two times a week. Resident 2 stated that the stair training was necessary because her residence has a second floor. In a subsequent interview at 4:22 p.m., in the presence of the DOR, Resident 3 stated that the stair training was done frequently and during her therapy. Resident 3 stated that she has received this type of therapy since her admission. A review of the facility's document titled, "Physical therapy job description," indicated associated responsibilities were to use professional judgement to ensure safety of self, patients, and others at all times. A review of the facility's undated policy titled, "Falling star program," indicated all residents would be closely monitored by staff for safety, and proper positioning of the resident. A review of the facility's undated policy titled, "Gait Belt Policy," indicated gait belts were to be used to transfer and ambulate all residents who needs "hands on" or assistance in moving from one place to another. The policy indicated the belt was primarily used for safety purposes for the resident and staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NOBZ11 Facility ID: CA940000062 If continuation sheet 15 of 15