Alamitos West Health & Rehab: Repositioning Order Ignored - CA
The inspection, completed August 22, 2025, was triggered by a complaint. Inspectors focused on one resident, identified in records as Resident 1, who had been admitted to the facility and carried diagnoses of Parkinson's disease, contracture of the right ankle, and abnormalities in gait and mobility. His MDS assessment showed he was fully dependent on staff for getting in and out of bed and for transfers, and needed substantial assistance just to roll from one side to the other. He could not reposition himself.
His physician had addressed that directly. An order dated April 18, 2025, required staff to reposition him two hours on his left side, then two hours on his right side, every four hours while he was in bed, every shift. The purpose stated in the order was to help with leg involuntary contraction.
On the morning of August 15, inspectors walked into his room at 8:47 a.m. and found him lying on his back, head of the bed elevated. They came back at 10:28 a.m. He was still on his back. At 11:28 a.m., still on his back. At 3:00 p.m., still on his back.
Between the first and second observations, inspectors spoke with the nursing assistant, identified as CNA 1, who was responsible for his care. They asked whether the resident could turn himself. CNA 1 said no, I have to help him. They asked how often. CNA 1 said as needed, when he tells us.
That afternoon, after the 3:00 p.m. observation, inspectors went back to CNA 1 and asked directly whether the resident had been repositioned that day. CNA 1 said he had only been pulled up in bed.
Four days later, inspectors spoke with a second nursing assistant, CNA 3. CNA 3 said yes, the resident was being repositioned. The description that followed was a pillow placed under his arms so he doesn't lean too much to one side, rotated left and right. Inspectors asked whether CNA 3 had moved the resident's body to his left or right side. CNA 3 said no, he doesn't like it.
The director of nursing was interviewed on August 20. She acknowledged the findings. She said the resident preferred to lie on his back. Then she said the physician's order to reposition him every two hours on alternating sides should have been discontinued.
It had not been discontinued. As of the inspection, the order was still active.
That gap, between an order on the chart and what staff were actually doing, is what the inspection captured. The facility's own policy on physician orders, revised in July 2025, states that all orders must be specific and complete with all necessary details to carry out the prescribed order without question. The repositioning order was specific. It named the sides, the intervals, the purpose. What it could not do was make anyone follow it.
The deficiency was cited at a level of potential for minimal harm, the lowest tier on CMS's harm scale. That classification reflects what inspectors could document, not what prolonged immobility does to a person with Parkinson's and a contracted ankle who cannot shift his own weight. Pressure injuries can develop within hours on bony prominences in patients who cannot reposition themselves. The inspection report does not state that Resident 1 developed a pressure injury. It also does not state that anyone checked.
What the record shows is a man lying on his back from at least 8:47 in the morning until at least 3:00 in the afternoon, with a nursing assistant who understood the order as something that applied only when the resident spoke up, and a director of nursing who responded to the findings by saying the order should have been taken off the chart months ago.
It was still on the chart.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alamitos West Health & Rehabilitation from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
ALAMITOS WEST HEALTH & REHABILITATION in LOS ALAMITOS, CA was cited for violations during a health inspection on August 22, 2025.
The inspection, completed August 22, 2025, was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.