Alamitos West Health & Rehab: Records Falsified - CA
She hadn't done it.
When inspectors visited the resident that morning, he told them directly: no one had brought him his toothbrush. An hour later, inspectors found CNA 3, as she's identified in the report, and asked her about the oral care setup. She pointed to the top of the dresser on the right side of the bed. When asked whether she had set it up for the resident, she said, "I don't think I did, I had two showers today."
The next morning, inspectors called her. She acknowledged she had documented that the resident received oral care on the day shift of August 19. She acknowledged she had not provided it.
The director of nursing was made aware. She acknowledged the findings.
That false entry is one piece of a larger documentation failure that inspectors detailed across two days of records for the same resident, identified only as Resident 1. What those records show, or rather what they don't show, is a nursing staff that left treatment after treatment uncharted, with no way to determine whether the care was ever delivered.
Resident 1's Treatment Administration Record for August 2025 was missing entries from licensed nurses across the entirety of August 9 and 10. The gaps were not minor. Inspectors listed eight separate physician's orders that had no documentation of completion on those days.
Nurses were ordered to apply fluocinonide cream, a topical treatment for inflammation and itching, twice daily at 9 a.m. on both days. No entries. They were ordered to get the resident out of bed and into a wheelchair each morning. No entries. The resident had blanchable redness on both heels, a condition where skin turns pale under pressure and returns to its normal color when released, indicating restricted blood flow, and nurses were ordered to float the heels every shift to relieve pressure. For the day shifts on August 9 and 10, and the night shift on August 10, there was nothing in the record to show it was done.
The same blank spaces appeared for the foot brace, which was ordered on at all times during the day shift. For monitoring of an ingrown toenail on the left first toe, ordered every shift. For the PRAFO, a pressure relief ankle foot orthosis worn on both lower extremities while in bed, ordered on at all times as tolerated.
On August 14, inspectors sat down with LVN 1 and went through the missing documentation. The nurse confirmed what inspectors already knew: the licensed nurses had not charted. A check mark in the TAR would indicate a task was completed. There were no check marks.
Inspectors asked LVN 1 how the facility could know whether any of those tasks had actually been done, given that the record was empty. "I'm not sure," the nurse said.
That answer sits at the center of what makes documentation failures dangerous in a nursing home setting. The TAR is not paperwork for its own sake. It is how one nurse communicates to the next nurse what was done, when, and whether the resident responded. A resident with blanchable heel redness is a resident at risk of developing a pressure injury. Floating the heels, repositioning the foot so it doesn't rest on the mattress, is a direct intervention to prevent that from getting worse. If it isn't charted, the next nurse coming on shift has no way to know it happened. If it isn't charted across two full days, the gap in care may be invisible until the skin breaks down.
The same logic applies to the PRAFO. It applies to the ingrown toenail. It applies to the cream for the itching.
The director of nursing, interviewed on August 20, verified all of it.
What the inspection describes, then, is two distinct but connected failures at the same facility, involving the same resident, within the same month. In the first, nurses simply didn't document. In the second, a nursing assistant documented something that didn't happen.
One failure leaves a blank. The other fills the blank with a lie.
The CNA's explanation, that she had two showers to give that morning, is the kind of detail that appears unremarkable until you consider what it represents. Oral care after meals is a basic hygiene task, ordered twice daily for this resident. On August 19, it didn't get done. It got recorded as done anyway. Whether that was carelessness or a deliberate decision to avoid a gap in the chart, the effect is the same: a record that tells the next caregiver, and any supervisor reviewing it, that the resident's teeth were brushed at 8:42 in the morning.
They weren't.
The resident, when inspectors asked him directly, knew. He said no one had brought it to him. His toothbrush was sitting on top of the dresser.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
ALAMITOS WEST HEALTH & REHABILITATION in LOS ALAMITOS, CA was cited for violations during a health inspection on August 22, 2025.
When inspectors visited the resident that morning, he told them directly: no one had brought him his toothbrush.
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.