Health inspection·January 21, 2022

F 0550 Certified Nurse Assistant (CNA 7) provided a partial bed bath for Resident 96. Level of Harm - Minimal harm or potential for actual harm On 1/20/22 at 10:19 a.m. during an interview with LVN 4 she stated Resident 96 was alert and oriented and able to verbalize his needs. Residents Affected - Few On 1/20/22 at 3:23 p.m. during an interview with LVN 4, the LVN stated CNA 5 and CNA 7 she did not receive a report about Resident 96 complaining of pain before or during showering. LVN 4 stated when residents complain of pain, she will assess the resident for verbal or nonverbal ques. LVN 4 stated she would try nonpharmacological (therapy that does not involve drugs) interventions first and if that was not effective would then do pharmacological (medication) interventions. On 1/20/22 at 3:38 p.m. during an interview with CNA 7, the CNA stated on 1/17/2022 Resident 96 refused to shower but LVN 4 convinced him to take a shower. CNA 7 stated Resident 96 complained about his legs touching together which caused pain. CNA 7 stated if a resident complained of pain or care she will stop touching the resident and report to the LVN or whoever was in charge. CNA 7 stated she did not report any complaints of pain because she was always careful when providing care to Resident 96. On 1/20/22 at 3:58 p.m. during an interview with the Director of Nursing (DON), the DON stated when asked if she thought rough handling was considered abuse the DON stated yes. On 1/21/22 at 9:03 a.m. during an interview Registered Nurse (RN 2) stated the protocol for a CNA when a resident reports pain during care was for the CNA to stop and tell the charge nurse or supervisor, then the charge nurse or supervisor should assess the resident and ask if the resident had any pain. The licensed nurse will then determine the extent of the pain, check the doctor's orders for pain medication and if no order was available then call the doctor to obtain orders. RN 2 stated the CNA should stop care and report to the charge nurse when a resident reports pain during care. RN 2 stated the charge nurse should assess the resident and try nonpharmacological intervention then give pain medication. If the pain medication is not effective call the doctor. A review of Resident 96's Pain Assessment Flowsheet dated 1/17/2022 indicated Resident 96 received pain medication once at 2:00 p.m. for severe pain, eight out of 10 (numeric pain scale 0 to 10, being the highest severity). A record review of the Licensed Nurse Progress Notes dated 1/17/2022 at 10:20 p.m. indicated Resident 96 had a complaint with care. A review of the facility's policy and procedure titled Resident Rights, revised 9/2017 indicated the facility must protect the rights of each resident to consent or refuse any treatment or procedure or participation in experimental research. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 2 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for four of the 12 residents (Residents 4,6,15 and 199). These deficient practices violated the residents' and/or the resident representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care. Findings: a. During a review of Resident 15's Face Sheet (admission Record) indicated that the resident was admitted to the facility on [DATE], with diagnoses that include hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to the brain caused by disrupted blood flow), hyperlipidemia (high levels of fat particles in the blood), anemia ( condition in which the blood does not have enough healthy red blood cells to carry oxygen to the body's tissues) and depression. During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 11/15/2021, indicated that the resident had moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating and making decisions that affect everyday life). The MDS indicated that the resident required limited assistance in bed mobility but required extensive assistance in bathing, transferring between bed to wheelchair/ or chair, dressing, toilet use, and personal hygiene. b. During a review of Resident 6's Face Sheet( admission Record) indicated that the resident was readmitted to the facility on [DATE], with diagnoses that include severe sepsis with septic shock (body's overwhelming and life- threatening response to infection), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (chronic disease associated with abnormally high levels of sugar glucose in the blood) and hyperlipidemia (high levels of fat particles in the blood). During a review of Resident 6's MDS (MDS- a standardized assessment and screening tool) dated 10/15/2021 indicated that the resident's cognition (mental action or process of acquiring knowledge and understanding through thought, experience and senses) was intact. The MDS indicated that the resident required limited assistance in bed mobility, transferring from bed to wheelchair, locomtion on and off unit, dressing , toilet use, and personal hygiene. c. During a review of Resident 4's Face Sheet (admission Record) indicated that the resident was admitted to the facility on [DATE] diagnoses that include hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to the brain caused by disrupted blood flow),osteomyelitis multiple sites (inflammation of the bone due to infection), methicillin-resistant Staphylococcus Aureus infection ( MRSA-a bacterial infection resistant to many antibiotics), thrombosis of left popliteal vein (blood clot in the vein), atrial fibrillation (abnormal and irregular heartbeat that can lead to blood clots), congestive heart failure( CHF-a condition where the heart cannot pump enough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 3 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blood to the body), hyperlipidemia (high level of fat particles in the blood) hypertension (high blood pressure), and dysphagia (a condition where it is difficult to swallow). During a review of Resident 4's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/14/21 indicated that the resident the resident's cognition (mental action or process of acquiring knowledge and understanding through thought, experience and senses) was intact. The MDS indicated that the resident required extensive assistance in transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. d. During a review of Resident 199's Face Sheet (admission Record) indicated that the resident was admitted on [DATE] with diagnoses that included cellulitis (serious bacterial skin infection), idiopathic autonomic neuropathy (a condition where there is damage of the peripheral nerves where the cause cannot be determined).and esophagitis (inflammation that damages the lining of the tube that connects the throat to the stomach). During a review of Resident 199's History and Physical Examination indicated that the resident has the capacity to understand and make decisions. During an interview on 1/20/22, at 11:11 a.m., with Director of Nursing (DON), DON stated that Social Services Director (SSD) handled Advance Directives, but licensed nurses could oversee if the SSD was unavailable. The DON stated the Advance Health Care Directive Acknowledgement form should be completed with initials either by the responsible party or resident. The initials on the form meant the resident or responsible party acknowledged the information provided by the facility. During an interview on 1/20/22, at 2:29 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that if the initials of resident were not present on the Advance Directive Acknowledgement form, it was incomplete and not done. During an interview on 1/20/22, at 3:49 p.m., with Registered Nurse 2(RN 2), RN 2 stated that the Advance Directive Acknowledgement form could not be located after going through the closed chart (medical records) for Resident 15, with the assistance of Medical Record Assistant (MRA). During an interview on 1/21/22, at 3:50 p.m., with Administrator (ADM), the ADM stated Advance Directives Acknowledgement form should be offered to all residents and if the form was not complete and not done if the form was not initialed by residents or resident representative. A review of Advance Directive Acknowledgement Forms of Residents 4 and 15 indicated that the forms were not filled up or initials of residents or resident representatives were not found. Resident 199's and Resident 6 's Advance Directive Acknowledgement Form were not in the chart (medical record). During a record review of facility's policy titled Advance Directives, revised on April 2017, indicated that the resident will be provided with written information concerning the resident's rights under State law to accept or refuse medical or surgical treatment and resident's rights to prepare an advance directive prior or upon admission. The policy stated that the resident or their responsible party will be asked if the resident has completed an advance directive and the facility will provide a copy of the document for the resident's clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 4 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a bowel and bladder incontinence care plan for one of two residents (Resident 8). This failure resulted in the delay of interventions to prevent urinary tract infection [(UTIs), an infection in any part of your urinary system] and placed Resident 8 at risk for recurring UTIs. Findings: A review of the Resident 8's Face Sheet (admission record) indicated the resident was re-admitted on [DATE] with the diagnoses including unspecified encephalopathy (a condition of the brain that alters brain function or structure), diabetes (high blood sugar), hypertension (high blood pressure), and dementia (loss of cognitive functioning). A review of Resident 8's Licensed Nurses Progress Notes dated 11/06/2021, timed at 6:00 a.m. indicated Extensive assist provided with ADLS (activities of daily living). Kept clean and dry. A review of Resident 8's most current Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 01/09/2022 indicated that the resident's cognitive patterns were severely impaired, had no mood and behavioral signs and symptoms, required extensive assistance from staff for bed mobility, transfer, toilet use, personal hygiene, and bathing with two-person physical assistance. Resident 8 required assistance with eating and was always incontinent (unable to control) of bowel and bladder. A review of Resident 8's Physician Orders dated 12/20/21, time unknown, indicated Keflex (medication used to treat a wide variety of bacterial infections) 250 milligram (mg, unit of weight) by mouth three times a day for 14 days for UTI. A review of Resident 8's care plan dated 11/06/2021 indicated Resident 8 was at risk for further skin breakdown related to fragile skin, ageing process, incontinence of B & B (bowel and bladder), impaired mobility, requires assistance on ADLs (activities of daily living), use of psychotropic, anemia, diabetes, hypertension, and GERD (gastroesophageal reflux disease- a condition where stomach acid frequently flows back into the tube between the mouth and the stomach). A review of Resident 8's care plan dated 12/20/21 indicated Resident 8 was on ATB (antibiotic) therapy related to abnormal UA (urinalysis-urine test). During an interview on 1/20/2022 at 10:41 a.m. , CNA 8 stated Resident 8 required total care, can assist with movements when asked and required assistance with feeding during meals. CNA 8 stated because the resident was incontinent, they would make rounds on the resident and change the resident every 2 hours or as needed. CNA 8 stated if the resident was not changed, skin problems may occur. CNA 8 stated the type of interventions they have provided to the resident included asking if he had any pain, or offers fluid every one to two hours. During an interview on 1/20/2022 at 10:19 a.m., Licensed Vocational Nurse (LVN 3) stated Resident 8 was alert and oriented with confusion, was totally dependent on staff for ADLs, and incontinent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 5 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bowel and bladder. LVN 3 stated the interventions the resident required included keeping the resident dry, change incontinent pads every two hours to avoid skin breakdown and encourage fluid intake. LVN 3 stated that if fluids are not encouraged the resident could develop renal issues, have a change in condition, and decrease output. LVN 3 specified that the decrease output could cause UTIs and dysuria. During an interview and concurrent record review on 1/20/2022 at 12:09 p.m. with the Director of Nursing (DON), Laboratory report dated 12/18/2021 indicated that Resident 8 had a UTI. During a record review of Resident 8's on 1/20/2022 at 12:09 p.m. with the DON, care plans dated 12/20/2021, the DON stated the only documentation addressing Resident 8's incontinence was under the care plan addressing Resident 8's high risk for further skin breakdown. During a concurrent interview, the DON stated CNAs need to check residents frequently and if there are new residents, they should be informed by charge nurse the type of care the resident required. The DON also stated the purpose of the care plan was to provide the interventions the resident needs. DON stated if interventions were missing from the care plan, the staff would not be able to provide the required care to the resident. A review of the facility's policy Comprehensive Care Planning revised in February 2019 indicated on admission, based on information accompanying the resident and results of admission assessments completed by the licensed nurses, a baseline care plan will be developed to address minimum health care information required to properly care for each resident. Including goals and objectives. In addition the facility's policy indicated the plan of care must include measurable objectives and time frames and describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 6 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to revise the care plan (a presentation of information that easily describes the services and support being given to a person) after receiving wound care physician orders for one of two residents (Resident 199). This deficient practice placed the resident at risk for delay in wound care interventions. Findings: During a review of Resident 199's Resident Face Sheet (admission record), indicated that resident was admitted on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the right lower extremity and other idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where the cause cannot be determined). During a review of Resident 199's history and physical (H&P) examination dated 1/14/2022 indicated upon physical examination, resident had bilateral lower extremity deep tissue injury. During a review of Resident 199's Physician (MD) admission Order dated 1/13/2022 indicated treatment orders/wound management: Left lateral malleolus (bone on the outside of the ankle joint). pressure ulcer (PU) unstageable: cleanse with normal saline (NS), pat dry, apply Betadine (medication used to prevent or treat mild skin infections), cover with DD (dry dressing) and wrap with Kerlix (a white gauze dressing) QD (daily) for 30 days and left great toe P/U unstageable: cleanse with NS, pat dry and apply Betadine, cover with DD and wrap with Kerlix QD for 30 days. During a review of Resident 199's care plan dated 1/13/2022 indicated Resident 199 was at high risk for further skin breakdown related to un-stageable wound to left great toe. The care plan indicated an approach/intervention to cleanse the wound with NS, pat dry, apply. During a review of Resident 199's care plan dated 01/13/2022 indicated Resident 199 was at high risk for further skin breakdown related to un-stageable wound to left lateral malleolus. The care plan indicated an approach/intervention to cleanse the wound with NS, pat dry, apply. During interview on 1/20/2022 at 12:09 p.m. the Director of Nursing (DON) stated the purpose of the care plan was to document what care needs to be provided and to provide the whole picture of the resident. The DON stated if information was missing from the care plan then will not provide an accurate picture of the resident. She also stated the nursing staff would not be able to monitor effectiveness of the treatment. During an interview and observation on 1/20/2022 at 2:15 p.m. , Registered Nurse (RN 2) stated Resident 199 was on antibiotics for right foot cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). RN 2 observed both the resisent's feet were bandaged with white bandages. During a concurrent record review with RN 2, indicated the wound care physician assessed the resident and reclassified the wounds. Resident 199's Physician and Telephone Orders dated 1/19/2022 at 11:15 a.m. indicated reclassify left great toe unstageable P/U (pressure ulcer) to Stage 3: left great toe P/U stage 3: cleanse with NS, pat dry, apply Santyl ointment (medication used to help with healing of burns and skin ulcers) and cover with optifoam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 7 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (waterproof adhesive foam dressing for pressure ulcers) QD for 30 days, and reclassify left lateral malleolus unstageable P/U (pressure ulcer) to Stage 3: left lateral malleolus P/U stage 3: cleanse with NS, pat dry, apply Santyl ointment and cover with optifoam QD for 30 days. RN 2 stated the process after wounds are reclassified included updating the care plan immediately. RN 2 stated that there was no documentation of an updated care plan including the reclassified wounds. RN 2 stated that if the care plan was not updated to reflect the new orders then the approaches and interventions cannot be carried out. During an interview on 1/21/2022 at 8:25 a.m., Licensed Vocational Nurse (LVN 7) stated that the process when receiving new orders included faxing to pharmacy, documenting on the nurse's notes, and updating or creating a new care plan on the same day as the order was received. LVN 7 stated if the process was not followed then information can be missed or forgotten which would result in the interventions not being implemented. A review of the facility's policy dated 02/2019 titled Comprehensive Care Planning indicated that the care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 8 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the nursing staff met professional standards of quality and competency, for improper medication administration by two of nineteen (19) total licensed nurses in the facility. Residents Affected - Some These deficient practices had the potential for harm to three of three residents (Resident 32, 42and 44) on dialysis due to the risk of adverse reactions for medications administered without meals. Findings: 1a. During an observation, on 1/19/22, at 8:51 a.m., of Resident 32's morning medication administration (med pass) at Station 2 Medication Cart, the Licensed Vocational Nurse (LVN 3), administered one tablet of Metformin (medication used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) 500 milligrams (mg, unit of weight). No food nor meal was provided to Resident 32 prior to medication administration. A review of the prescription label for Metformin indicated, one (1) tablet by mouth with meals. During an interview, on 1/19/22, at 8:52 a.m., LVN 3, stated that Resident 3 had breakfast, less than an hour prior to the morning med pass. A review of Resident 32's medication orders, titled, Physician's admission Order, dated 1/1/22 to 1/31/22, indicated the start date 11/15/21, and the order, Metformin tablet [500 mg, one tablet three times a day with meals, diabetes mellitus], With Meals; 7:15 AM, 12:15 PM, 05:15 PM. Breakfast was scheduled at 7:15 a.m. A review of Resident 32's Face Sheet (admission record), the resident was admitted to the facility on [DATE], with a diagnoses including type 2 diabetes mellitus (type 2 diabetes develops when the pancreas makes less insulin than the body needs, and the body cells stop responding to insulin). 1b. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning medication administration (med pass) at Station 1 Medication Cart, Licensed Vocational Nurse (LVN 4) administered one tablet of Calcium Acetate (used to treat hyperphosphatemia, or too much phosphate in the blood, in patients with end stage kidney disease who are on dialysis. Calcium acetate works by binding with the phosphate in the food you eat, so that it is eliminated from the body without being absorbed) 667 mg (strength in milligram units) by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for calcium acetate indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., LVN 4, regarding meal time for Resident 44, the LVN stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Calcium Acetate 667 mg [1 capsule by mouth three times a day with meals], diagnosis ESRD (end stage renal disease, the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own. A patient with end-stage renal failure must receive dialysis or kidney transplantation in order to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 9 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 survive for more than a few weeks). Level of Harm - Minimal harm or potential for actual harm A review of Resident 44's, Face Sheet indicated the resident was admitted on [DATE], with diagnoses including end-stage renal disease, dependence on renal dialysis, and other disorders of phosphorus metabolism. Residents Affected - Some 1c. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning med pass at Station 1 Medication Cart, LVN 4 administered Sevelamer (Renvela, used to lower high blood phosphorus (phosphate) levels in patients who are on dialysis due to severe kidney disease. Dialysis removes some phosphate from your blood, but it is difficult to remove enough to keep the phosphate levels balanced) 800 mg in each tablet, two tablets, or 1,600mg, by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for Sevelamer indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., LVN 4, regarding Resident 44's meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Sevelamer .[800 mg, two (2) tablets or 1,600 mg, by mouth three times a day with meals], diagnosis ESRD. A review of Resident 44's, Face Sheet indicated the resident was admitted on [DATE], with diagnoses including end-stage renal disease, dependence on renal dialysis, and other disorders of phosphorus metabolism. 1d. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning med pass at Station 1 Medication Cart, LVN 4 administered Ferrous Sulfate (used to treat and prevent iron deficiency anemia. Iron helps the body to make healthy red blood cells, which carry oxygen around the body. Blood loss, pregnancy or too little iron in your diet can make your iron supply drop too low, leading to anemia) 325 mg Tablet, one tablet by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for Ferrous Sulfate indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., LVN 4, regarding Resident 44's meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's, Face Sheet the resident was admitted on [DATE] with diagnoses including anemia. A review of Resident 44's medication orders, titled, Physician's admission Order, dated 12/26/21, indicated the handwritten, Ferrous Sulfate 325 mg EC (enteric coated, coated with a material that permits transit through the stomach to the small intestine before the medication is released. The term enteric means of or relating to the small intestine), [1 tablet by mouth three times a day with meals], diagnosis Anemia (a condition in which there is a lack enough healthy red blood cells to carry adequate oxygen to the body's tissues. Having anemia, also referred to as low hemoglobin, can make a person feel tired and weak.). 1e. During an observation, on 1/20/22, at 8:13 a.m., of Resident 42's morning med pass at Station 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 10 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Medication Cart, LVN 4 administered Velphoro (sucroferric oxyhydroxide chewable, used for the control of serum phosphorus levels in adult chronic kidney disease patients on hemodialysis) 500 mg tablet, one tablet by mouth. No food nor meal was provided to Resident 42. A review of the prescription label for Velphoro indicated, .with meals. Residents Affected - Some During an interview, on 1/20/22, at 8:48 a.m., LVN 4, regarding meal time, stated, Breakfast comes out at 7:15 (a.m.). A review pf Resident 42's medication orders, titled, Physician Order Report, dated 1/1/22 to 1/31/22, indicated the start date 11/18/21, and the order, Velphoro (sucroferric oxyhydroxide) tablet, chewable, 500 mg, [1 tablet by mouth three times a day with meals, end stage renal disease] With Meals 7:15 AM, 12:15 AM, 05:15 PM. A review of Resident 42's, Face Sheet indicated the resident was admitted on [DATE], with a diagnoses including endstage renal disease, and dependence on renal dialysis. A review of the facility's nursing policy and procedures, titled, Medication Administration-General Guidelines, effective date October 2017, indicated, Administration .medications are administered in accordance with written orders of the attending physician. 2. During an observation, on 1/20/22, at 8:13 a.m., of Resident 42's morning med pass at Station 1 Medication Cart, LVN 4 was preparing to administer Lidocaine Ointment 5% (strength in percentage units) when the surveyor stopped her. A review of the prescription label for Lidocaine Ointment 5% indicated no amount to be applied. The label indicated, Lidocaine Ointment 5%, apply to affected area 20 minutes before hemodialysis on Tuesday, Thursday, and Saturday. During an interview, on 1/20/22, at 8:26 a.m., the licensed vocational nurse, LVN 4, regarding the amount of ointment to apply, stated. We don't have [amount], but this order needs to be clarified. During an interview, on 1/20/22, at 8:35 a.m., LVN 4 stated, Dose is half-inch, as she received clarification from the dialysis center. During an observation, on 1/20/22, after 8:35 a.m., LVN 4 acquired a flexible clear plastic ruler, measured the half-inch dose, and applied it to Resident 42 A review of Resident 42's, Face Sheet, indicated the resident was admitted on [DATE] with diagnoses inlcuding end stage renal disease, and dependence on renal dialysis. A review of the facility's nursing policy and procedures, titled, Medication Administration-General Guidelines, effective date October 2017, indicated, Preparation .Prior to administration, the medications and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .if there is any reason to question the dosage or directions, the physician's orders are checked for the correct dosage .Administration .medications are administered in accordance with written orders of the attending physician .the nurse .if necessary contacts the prescriber for clarification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 11 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the discharge summary was completed for one of two closed records residents (Resident 47). This deficient practice failed to folllow the requirements for residents' to have complete and accurate medical records. Findings: A review of Resident 47's Face Sheet (admission record), indicated that the resident was admitted on [DATE], with the diagnoses that included fracture of other parts of pelvis ( breakage of the bony structure near the base of the spine to which the legs are attached), anemia ( a condition in which the blood does not have enough healthy red blood cells to carry oxygen to body's tissues),depression, anxiety disorder, traumatic subdural hemorrhage (bleeding in the brain which usually related to head injury), and hematuria (blood in the urine). A review of History and Physical (H&P) examination, dated 11/17/21, indicated that the resident has the capacity to understand and make decisions. A review of the physician's order, dated 12/17/21, indicated an order to discharge resident to home. During an interview on 1/21/22, at 9:56 a.m., with Director of Medical Records (DMR), the DMR stated that when a resident was discharged from the facility documents like discharge summary , physician's discharge order, all other documents like vital signs, nursing notes, instructions for medications should be in the resident's chart (medical record). During a concurrent observation and interview on 1/21/22, at 10;00 am, with DMR, DMR stated that there is no date and time on the Physician's Discharge Summary. DMR stated, I am sorry. We have 30 days to complete the records when a resident is discharged . During an interview on 1/21/22, at 3:50 pm, with Administrator(ADM), ADM stated that the responsibility of medical record when resident is discharged to ensure the documentation of clinical record of a resident was complete and if not done, documents will not be accurate. The facility was not able to provide a policy regarding dischrge summary completeness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 12 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate perineal care to prevent urinary tract infection (UTI, an infection of any part of the urinary tract) for one of four residents (Resident 8). This deficient practice placed Resident 8 at risk for recurring UTIs. Findings: A review of the Resident's Face Sheet (admission record) indicated the Resident was re-admitted to the facility on [DATE] with the diagnoses of unspecified encephalopathy (a condition of the brain that alters brain function or structure), diabetes (abnormal blood sugar), hypertension (high blood pressure), and dementia (loss of cognitive functioning). A review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/09/2022 indicated that the resident's cognitive patterns were severely impaired, had no mood and behavioral signs and symptoms, required extensive assistance from staff for bed mobility, transfer, toilet use, personal hygiene, and bathing requiring two-person physical assistance. Resident 8 required assistance with eating and was always incontinent (unable to control) of bowel and bladder. During an observation on 1/19/2022 at 8:53 a.m., Resident 8 was awake and was able to respond to simple questions appropriately. During an interview on 1/19/2022 at 8:53 a.m. with Certified Nurse Assistant (CNA 8), the CNA stated that the resident was mostly awake during the day. During an interview on 1/20/2022 at 10:03 a.m. with Certified Nurse Assistant (CNA 2), stated Resident 8 needed total care and required the use of adult diapers (incontinent pads). CNA 2 stated Resident 8 needed to be changed and repositioned every 2 hours. CNA 2 stated it was very difficult to know what the resident needed because the resident does not speak much. During an interview on 1/20/2022 at 10:19 a.m. with Licensed Vocational Nurse (LVN 3) stated that Resident 8 was alert and oriented with some confusion, could verbalize pain, and was incontinent of bowel and bladder. According to LVN3, interventions the resident required included keeping skin dry and change incontinent pads every two hours to avoid skin breakdown. LVN 3 also stated that if fluids are not encouraged the resident could develop renal issues, have a change in condition, and decrease output. LVN 3 specified that the decrease output could cause UTIs and dysuria (painful urination). During an interview and concurrent record review on 1/21/2022 at 8:32 a.m. with Registered Nurse 2 (RN 2) of Resident 8's care plan dated 1/20/2022, indicated Resident 8 was at risk for UTI and urinary incontinence and skin breakdown. During a concurrent observation 1/21/2022 at 10:38 a.m., in Resident 8's room with Certified Nurse Assistant (CNA 9), was observed to have provided perineal care (cleansing of vaginal area) to Resident 8. No basin was observed at bedside. When asked how she provided peri care to the resident, CNA 9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 13 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she used two wet towels, brought in the resident's room inside a plastic bag. CNA 9 stated that she changed Resident 8's incontinent pad then cleaned the resident using two small towels, one towel for each area. During an interview on 1/21/2022 at 12:17 p.m. with the Restorative Nursing Assistant (RNA) who assisted CNA 9 during perineal care, stated CNA 9 used a wet towel to wipe Resident 8 from front to back. When asked where did the wet towels come from, the RNA stated that they were in a plastic bag when she entered the room to assist CNA 9. During an interview on 1/21/2022 at 12:19 p.m. the Director of Staff Development (DSD) stated the procedure for incontinent care included supplies such as a basin, (6) washcloths, soapy water, and gloves. The DSD stated the CNAs should explain to the resident what they are doing, have incontinent briefs available, bring extra bag for dirty items, pull the curtain, do proper hand hygiene, clean from outside going in for females, and when the CNA was done cleaning, they should change gloves and perform hand hygiene again. The DSD specified that a basin should be used when performing incontinence care and the CNAs should not deviate from that practice. A review of CNA 9's Certified Nursing Assistant Skills and Competency Validation-Orientation dated 10/15/2021 indicated that CNA 9 was competent in the skill of incontinent/skin care. A review of the facility's procedure titled Perineal Care revised on 6/2017 indicated the Purpose: the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident's skin condition. Also, the procedure indicated The following equipment and supplies will be necessary when performing this procedure: wash basin, towels, washcloth, soap (or other authorized cleansing agent); and personal protective equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 14 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that the change of shift narcotics reconciliation records, for one of two medication carts at the facility, were not missing a total of sixteen (16) licensed nurse signatures in the designated nurse signature boxes over a three (3) month period. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. 2. Ensure that nursing staff administered five (5) medications with meals, per physicians' orders, to three of four residents (Resident 32, 42 and 44) observed during the morning medication administration. This deficient practice had the potential for harm to the residents due to potential adverse effects of the medications. 3. Ensure that nursing staff applied a topical medication without clarification of the missing dose in the physician's order, in one of four residents (Resident 42) observed during the morning medication administration. This deficient practice had the potential for harm to the resident due to potential for underdosing or overdosing of the medication. Findings: 1. During an observation, on 1/18/22, at 2:40 p.m., of the Station 1, Medication Cart's the shift change narcotic (drugs with the potential for abuse and addiction controlled by the government) reconciliation sheets, titled, Controlled Drugs-Count Sign In/Out, indicated sixteen (16) blank, unsigned spaces with missing licensed nurses' signatures from 11/1/21 to 1/18/22. A review of the Controlled Drugs-Count Sign In/Out indicated the headings, Date, 7-3 Shift (7 a.m. to 3 p.m.), 3-11 Shift (3 p.m. to 11 p.m.), and 11-7 Shift (11 p.m. to 7 a.m.). Each shift heading included columns for two signature boxes, labeled Outgoing and Incoming and their respective shifts. The missing nurse signatures in the signature boxes were indicated on 11/13/21, Outgoing (3-11 shift); 11/13/21, Incoming (11-7 shift); 11/29/21, Outgoing (3-11 shift); 12/3/21, Incoming (7-3 shift); 12/3/21, Outgoing (7-3 shift); 12/19/21, Incoming (7-3 shift); 12/19/21, Outgoing (7-3 shift); 12/23/21, Incoming (7-3 shift); 12/23/21, Outgoing (7-3 shift); 12/29/21, Incoming (7-3 shift); 12/29/21, Outgoing (7-3 shift); 12/30/21, Incoming (3-11 shift); 12/30/21, Outgoing (3-11 shift); 1/1/22, Incoming (7-3 shift); 1/1/22, Outgoing (7-3 shift); and, 1/12/22, Outgoing (3-11 shift). During an interview, on 1/18/22, at 2:42 p.m., Licensed Vocational Nurse (LVN 2), regarding missing licensed nurse signatures, stated, I don't know with them, referring to the nurses who did not sign while the other nurses did sign during the shift changes. LVN 2 showed the surveyor his own signatures, signed at the same time as the other nurse, stating that he signed them correctly. A review of the, Controlled Drugs-Count Sign In/Out, indicated instructions on the top of the form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 15 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm The Incoming Licensed Nurse (LN) will count with the Outgoing Licensed Nurse at the start / end of the shift. Licensed Nurse must sign legibly with full signature and title. Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record. If there is an unresolved discrepancy with the count, notify the Nursing Supervisor. Residents Affected - Some A review of the facility's pharmacy policy and procedures, titled, Controlled Medication Storage, effective date August 2014, indicated, Procedures .At each shift change, a physical inventory of all controlled substances, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. 2. During an observation, on 1/19/22, at 8:51 a.m., of Resident 32's morning medication administration (med pass) at Station 2, Medication Cart, Licensed Vocational Nurse (LVN 3), administered one tablet of Metformin (medication used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes. With this type of diabetes, insulin produced by the pancreas is not able to get sugar into the cells of the body where it can work properly) 500 mg (strength in milligram units). No food nor meal was provided to Resident 32. A review of the prescription label for Metformin indicated, one (1) tablet by mouth with meals. During an interview, on 1/19/22, at 8:52 a.m., the licensed vocational nurse, LVN 3, stated that Resident 3 had breakfast, less than an hour prior to the morning med pass. A review of Resident 32's medication orders, titled, Physician's admission Order, dated 1/1/22 to 1/31/22, indicated the start date 11/15/21, and the order, Metformin tablet [500 mg, one tablet three times a day with meals, diabetes mellitus], With Meals; 07:15 AM, 12:15 PM, 05:15 PM. Breakfast was scheduled at 7:15 a.m. A review of Resident 32's, Face Sheet (document that gives a resident's information at a quick glance. Face sheets can include contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), original admission date 5/4/21, indicated diagnoses including Type 2 diabetes mellitus (type 2 diabetes develops when the pancreas makes less insulin than the body needs, and the body cells stop responding to insulin.). 2b. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning medication administration (med pass) at Station 1, Medication Cart, Licensed Vocational Nurse (LVN 4), administered one tablet of Calcium Acetate (used to treat hyperphosphatemia, or too much phosphate in the blood, in patients with end stage kidney disease who are on dialysis. Calcium acetate works by binding with the phosphate in the food you eat, so that it is eliminated from the body without being absorbed) 667 mg (strength in milligram units) by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for calcium acetate indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., LVN 4, regarding meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Calcium Acetate 667 mg [1 capsule by mouth three times a day with meals], diagnosis ESRD (end stage renal disease, the final, permanent stage of chronic kidney disease, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 16 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some where kidney function has declined to the point that the kidneys can no longer function on their own. A patient with end-stage renal failure must receive dialysis or kidney transplantation in order to survive for more than a few weeks). A review of Resident 44's, Face Sheet, admission date 12/26/21, indicated diagnoses including end-stage renal disease, dependence on renal dialysis, and Other disorders of phosphorus metabolism. 2c. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning med pass at Station 1, Medication Cart, LVN 4 administered Sevelamer (Renvela, used to lower high blood phosphorus (phosphate) levels in patients who are on dialysis due to severe kidney disease. Dialysis removes some phosphate from your blood, but it is difficult to remove enough to keep the phosphate levels balanced) 800 mg in each tablet, two tablets, or 1,600mg, by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for Sevelamer indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., the licensed vocational nurse, LVN 4, regarding meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Sevelamer .[800 mg, two (2) tablets or 1,600 mg, by mouth three times a day with meals], diagnosis ESRD. A review of Resident 44's, Face Sheet, admission date 12/26/21, indicated diagnoses including end-stage renal disease, dependence on renal dialysis, and Other disorders of phosphorus metabolism. 2d. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning med pass at Station 1, Medication Cart, LVN 4 administered Ferrous Sulfate (used to treat and prevent iron deficiency anemia. Iron helps the body to make healthy red blood cells, which carry oxygen around the body. Blood loss, pregnancy or too little iron in your diet can make your iron supply drop too low, leading to anemia) 325 mg Tablet, one tablet by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for Ferrous Sulfate indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., the licensed vocational nurse, LVN 4, regarding meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's, Face Sheet, admission date 12/26/2021 (December 26, 2021), indicated diagnoses including Anemia, unspecified. A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Ferrous Sulfate 325 mg EC (enteric coated, coated with a material that permits transit through the stomach to the small intestine before the medication is released. The term enteric means of or relating to the small intestine), [1 tablet by mouth three times a day with meals], diagnosis Anemia (a condition in which there is a lack enough healthy red blood cells to carry adequate oxygen to the body's tissues. Having anemia, also referred to as low hemoglobin, can make a person feel tired and weak.). 2e. During an observation, on 1/20/22, at 8:13 a.m., of Resident 42's morning med pass at Station (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 17 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm 1, Medication Cart, LVN 4 administered Velphoro (sucroferric oxyhydroxide chewable, used for the control of serum phosphorus levels in adult chronic kidney disease patients on hemodialysis) 500 mg tablet, one tablet by mouth. No food nor meal was provided to Resident 42. A review of the prescription label for Velphoro indicated, .with meals. Residents Affected - Some During an interview, on 1/20/22, at 8:48 a.m., LVN 4, regarding meal time, stated, Breakfast comes out at 7:15 (a.m.). A review pf Resident 42's medication orders, titled, Physician Order Report, dated 1/1/22 to 1/31/22, indicated the start date 11/18/21, and the order, Velphoro (sucroferric oxyhydroxide) tablet, chewable, 500 mg, [1 tablet by mouth three times a day with meals, end stage renal disease] With Meals 07:15 AM, 12:15 AM, 05:15 PM. A review of Resident 42's, Face Sheet, admission date 10/30/21, indicated diagnoses including End stage renal disease, and Dependence on renal dialysis. For 2a., 2b., 2c., 2d., and 2e. (above): A review of the facility's nursing policy and procedures, titled, Medication Administration-General Guidelines, effective date October 2017, indicated, Administration .medications are administered in accordance with written orders of the attending physician. 3. During an observation, on 1/20/22, at 8:13 a.m., of Resident 42's morning med pass at Station 1, Medication Cart, LVN 4 was preparing to administer Lidocaine Ointment 5% (strength in percentage units) when the surveyor stopped her. A review of the prescription label for Lidocaine Ointment 5% indicated no amount to be applied. The label indicated, Lidocaine Ointment 5%, apply to affected area 20 minutes before hemodialysis on Tuesday, Thursday, and Saturday. During an interview, on 1/20/22, at 8:26 a.m., LVN 4, regarding the amount of ointment to apply, stated. We don't have [amount], but this order needs to be clarified. During an interview, on 1/20/22, at 8:35 a.m., LVN 4 stated, Dose is half-inch, as she received clarification from the dialysis center. During an observation, on 1/20/22, after 8:35 a.m., LVN 4 acquired a flexible clear plastic ruler, measured the half-inch dose, and applied it to Resident 42 A review of Resident 42's, Face Sheet, admission date 10/30/2021 (October 30, 2021), indicated diagnoses including End stage renal disease, and Dependence on renal dialysis. A review of the facility's nursing policy and procedures, titled, Medication Administration-General Guidelines, effective date October 2017, indicated, Preparation .Prior to administration, the medications and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .if there is any reason to question the dosage or directions, the physician's orders are checked for the correct dosage .Administration .medications are administered in accordance with written orders of the attending physician .the nurse .if necessary contacts the prescriber for clarification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 18 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the medication error rate of less than five (5) percent, due to six (6) medication administration errors involving three of four residents (Resident 32, 42 and 44) observed during medication administration (med pass). Residents Affected - Some This deficient practice of a medication administration error rate of twenty percent (20 %) exceeded the five (5) percent threshold. Findings: 1a. During an observation, on 1/19/22, at 8:51 a.m., of Resident 32's morning medication administration (med pass) at Station 2, Medication Cart, the licensed vocational nurse, LVN 3, administered one tablet of Metformin (medication used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes. With this type of diabetes, insulin produced by the pancreas is not able to get sugar into the cells of the body where it can work properly) 500 mg (strength in milligram units). No food nor meal was provided to Resident 32. A review of the prescription label for Metformin indicated, one (1) tablet by mouth with meals. During an interview, on 1/19/22, at 8:52 a.m., the licensed vocational nurse, LVN 3, stated that Resident 3 had breakfast, less than an hour prior to the morning med pass. A review of Resident 32's medication orders, titled, Physician's admission Order, dated 1/1/22 to 1/31/22, indicated the start date 11/15/21, and the order, Metformin tablet [500 mg, one tablet three times a day with meals, diabetes mellitus], With Meals; 07:15 AM, 12:15 PM, 05:15 PM. Breakfast was scheduled at 7:15 a.m. A review of Resident 32's, Resident Face Sheet (document that gives a resident's information at a quick glance. Face sheets can include contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), original admission date 5/4/21, indicated a [AGE] year old male with a diagnosis of Type 2 diabetes mellitus (type 2 diabetes develops when the pancreas makes less insulin than the body needs, and the body cells stop responding to insulin. They don't take in sugar as they should. Sugar builds up in the blood.), among other diagnoses. 1b. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning medication administration (med pass) at Station 1, Medication Cart, the licensed vocational nurse, LVN 4, administered one tablet of Calcium Acetate (used to treat hyperphosphatemia, or too much phosphate in the blood, in patients with end stage kidney disease who are on dialysis. Calcium acetate works by binding with the phosphate in the food you eat, so that it is eliminated from the body without being absorbed) 667 mg (strength in milligram units) by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for calcium acetate indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., the licensed vocational nurse, LVN 4, regarding meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's medication orders, titled, Physician's admission Order, order date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 19 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm 12/26/21, indicated the handwritten, Calcium Acetate 667 mg [1 capsule by mouth three times a day with meals], diagnosis ESRD (end stage renal disease, the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own. A patient with end-stage renal failure must receive dialysis or kidney transplantation in order to survive for more than a few weeks). Residents Affected - Some A review of Resident 44's, Resident Face Sheet, admission date 12/26/21, indicated a [AGE] year old male with diagnoses of end-stage renal disease, dependence on renal dialysis, and Other disorders of phosphorus metabolism, among other diagnoses. 1c. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning med pass at Station 1, Medication Cart, LVN 4 administered Sevelamer (Renvela, used to lower high blood phosphorus (phosphate) levels in patients who are on dialysis due to severe kidney disease. Dialysis removes some phosphate from your blood, but it is difficult to remove enough to keep the phosphate levels balanced) 800 mg in each tablet, two tablets, or 1,600mg, by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for Sevelamer indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., the licensed vocational nurse, LVN 4, regarding meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Sevelamer .[800 mg, two (2) tablets or 1,600 mg, by mouth three times a day with meals], diagnosis ESRD. A review of Resident 44's, Resident Face Sheet, admission date 12/26/21, indicated a [AGE] year old male with diagnoses of end-stage renal disease, dependence on renal dialysis, and Other disorders of phosphorus metabolism, among other diagnoses. 1d. During an observation, on 1/20/22, at 8:47 a.m., of Resident 44's morning med pass at Station 1, Medication Cart, LVN 4 administered Ferrous Sulfate (used to treat and prevent iron deficiency anemia. Iron helps the body to make healthy red blood cells, which carry oxygen around the body. Blood loss, pregnancy or too little iron in your diet can make your iron supply drop too low, leading to anemia) 325 mg Tablet, one tablet by mouth. No food nor meal was provided to Resident 44. A review of the prescription label for Ferrous Sulfate indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., the licensed vocational nurse, LVN 4, regarding meal time, stated, He ate breakfast at 7:30 (a.m.), [breakfast] comes out at 7:15 (a.m.). A review of Resident 44's, Resident Face Sheet, admission date 12/26/2021 (December 26, 2021), indicated a [AGE] year old male with a diagnosis of Anemia, unspecified. A review of Resident 44's medication orders, titled, Physician's admission Order, order date 12/26/21, indicated the handwritten, Ferrous Sulfate 325 mg EC (enteric coated, coated with a material that permits transit through the stomach to the small intestine before the medication is released. The term enteric means of or relating to the small intestine), [1 tablet by mouth three times a day with meals], diagnosis Anemia (a condition in which there is a lack enough healthy red blood cells to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 20 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some carry adequate oxygen to the body's tissues. Having anemia, also referred to as low hemoglobin, can make a person feel tired and weak.). 1e. During an observation, on 1/20/22, at 8:13 a.m., of Resident 42's morning med pass at Station 1, Medication Cart, LVN 4 administered Velphoro (sucroferric oxyhydroxide chewable, used for the control of serum phosphorus levels in adult chronic kidney disease patients on hemodialysis) 500 mg tablet, one tablet by mouth. No food nor meal was provided to Resident 42. A review of the prescription label for Velphoro indicated, .with meals. During an interview, on 1/20/22, at 8:48 a.m., the licensed vocational nurse, LVN 4, regarding meal time, stated, Breakfast comes out at 7:15 (a.m.). A review pf Resident 42's medication orders, titled, Physician Order Report, dated 1/1/22 to 1/31/22, indicated the start date 11/18/21, and the order, Velphoro (sucroferric oxyhydroxide) tablet, chewable, 500 mg, [1 tablet by mouth three times a day with meals, end stage renal disease] With Meals 07:15 AM, 12:15 AM, 05:15 PM. A review of Resident 42's, Resident Face Sheet, admission date 10/30/21, indicated a [AGE] year old male with a diagnosis of End stage renal disease, and Dependence on renal dialysis. For 1a., 1b., 1c., 1d., and 1e. (above): A review of the facility's nursing policy and procedures, titled, Medication Administration-General Guidelines, effective date October 2017, indicated, Administration .medications are administered in accordance with written orders of the attending physician. 2. During an observation, on 1/20/22, at 8:13 a.m., of Resident 42's morning med pass at Station 1, Medication Cart, LVN 4 was preparing to administer Lidocaine Ointment 5% (strength in percentage units) when the surveyor stopped her. A review of the prescription label for Lidocaine Ointment 5% indicated no amount to be applied. The label indicated, Lidocaine Ointment 5%, apply to affected area 20 minutes before hemodialysis on Tuesday, Thursday, and Saturday. During an interview, on 1/20/22, at 8:26 a.m., the licensed vocational nurse, LVN 4, regarding the amount of ointment to apply, stated. We don't have [amount], but this order needs to be clarified. During an interview, on 1/20/22, at 8:35 a.m., LVN 4 stated, Dose is half-inch, as she received clarification from the dialysis center. During an observation, on 1/20/22, after 8:35 a.m., LVN 4 acquired a flexible clear plastic ruler, measured the half-inch dose, and applied it to Resident 42 A review of Resident 42's, Resident Face Sheet, admission date 10/30/2021 (October 30, 2021), indicated a [AGE] year old male with a diagnosis of End stage renal disease, and Dependence on renal dialysis. A review of the facility's nursing policy and procedures, titled, Medication Administration-General Guidelines, effective date October 2017, indicated, Preparation .Prior to administration, the medications and dosage schedule on the resident's medication administration record (MAR) is compared with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 21 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm the medication label .if there is any reason to question the dosage or directions, the physician's orders are checked for the correct dosage .Administration .medications are administered in accordance with written orders of the attending physician .the nurse .if necessary contacts the prescriber for clarification. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 22 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared by methods that conserved flavor, nutritional value, and texture of foods for all residents except the residents on tube feeding. Residents Affected - Some This deficient practice had the potential for weight loss for 41 of 46 residents who are on regular mechanical soft, or puree diet due to poor meal intake. Findings: During a concurrent observation and interview on 1/18/2022, at 10:44 a.m., with dietary cook (cook 1), the pork chops, rice, and broccoli were observed cooked on the steam table. [NAME] 1 confirmed the food items were cooked and was being kept warm on the steam table for the noon meal. On 1/18/2022, at 12:28 p.m., with the Registered Dietitian (RD), a sample of the food (test tray) for flavor and texture was performed. RD stated the puree rice tasted like powdered starch, sticky, and no flavor. The pork chop was very dry and difficult to chew. The broccoli was yellowish brown in color and could be mashed with the back of a spoon with light pressure. Expectation and research studies have demonstrated food which was prepared properly, in a palatable manner and looks attractive increased the nutritional intake in the elderly population ([NAME], 2014, Divert, 2014). The nutritional value of food, in particular vegetables, which are heated multiple times compromises both the palatability and nutritional value of food (Nutrition.gov). During a review of the facility's policy and procedure titled, Food Preparation, dated 2018, indicated meat, fish, egg, and milk products will be prepared as closed to serving time as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 23 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to ensure a mechanical soft diet (food textures modified residents who have difficulty chewing and swallowing) was prepared to meet need of 9 residents. The spreadsheet indicated ground pork chop for a mechanical soft diet. This failure had the potential to result in choking and aspiration pneumonia for 9 residents on a mechanical soft diet. Findings: During a concurrent meal preparation observation and interview with [NAME] 1 and [NAME] 2 on 1/18/2022, at 11:57 a.m., [NAME] 2 was serve the foods from the steam table to the resident's plate. [NAME] 2 would cut the pork chops with scissors into random size pieces for the mechanical soft diet. [NAME] 1 would check the dietary meal ticket which include resident's name, room number, diet order and likes and dislikes and place food tray into the tray cart. [NAME] 1 was questioned why that pork chop was not grounded for a mechanical diet [NAME] 1 shrugged his shoulders and did not answer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 24 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on interview, and record review the facility failed to provide a meal substitute for one of five residents (Resident 27). Residents Affected - Few This deficient practice had the potential to cause the residents' nutritional status to decline. Findings: On 1/18/22 at 10:24 a.m. during an interview with Resident 27, the resident stated I don't like the food, it is always the same, sometimes it is okay. Resident 27 stated I always ask for different food and I do not get it. A review of Resident 27's admission record (Face Sheet) dated 12/02/2021 indicated, diagnoses including a fracture of the lateral malleolus of right tibia(a broken bone on the ankle), Non-ST elevation (NSTEMI) myocardial infarction (a type of heart attack) and hypertensive heart disease (changes on the left side of the heart and coronary arteries as a result of high blood pressure that is present over a long period of time)with heart failure(a heart disease that affects pumping action of the heart muscles). A review of Resident 27's History and Physical Examination dated 12/2/2021 indicated, Resident 27 had the capacity to understand and make decisions. A record review of Resident 27's Physician's admission Order dated 12/2/21 indicted, Resident 27 was on a regular diet and required weekly weights for four weeks. During a review of the Vitals Report dated 12/02 to 1/18/22, indicated Resident 27 ate less than 75% of his meal 34 times and refused his meals twice. A record review of Resident 27's Care Plan dated 12/2/21 indicated Resident 27 was on a regular diet, the goal was for Resident 27 to consume 75% or more or meals served daily without showing signs or symptoms of difficulty eating and the plan was to offer food substitutes within dietary limits if intake is less than 75%. A record review of Resident 27's Care Plan titled Nutrition dated 12/2/2021 indicated the goal was the resident will consume at least 75% of the diet served every meal. The plan was to offer food substitutes if diet given is refused. A review of Resident 27's Licensed Nurse Progress Notes dated 1/16/22 indicated Resident 27 always wanted to get food. On 1/20/22 at 1:20 p.m. during a concurrent interview and record review with Licensed Vocational Nurse (LVN 4) and Registered Nurse (RN 2) when reviewing the diet flowsheet and substitutions offered dated 1/02/2022 to 1/31/2022, indicated no documentation of Resident 27 being offered meal substitutions when refusing meals or eating less than 75% of the meal. RN 2 stated when a resident refuses a meal, the resident is offered a meal substitution and it is documented in the computer or on the diet flow sheet. RN 2 and LVN 4 both agreed there is no documentation of Resident 27 being offered a meal substitution on the diet flowsheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 25 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm A record review of the policy titled Resident Rights, revised on 9/2017 indicated the resident has the right to participate in his/her treatment and support the resident by facilitating the inclusion of the resident or their representatives, including an assessment of the resident's strengths and needs and incorporating the resident's personal and cultural preferences in the development of goals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 26 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure to store food in a safe and sanitary manner to prevent the growth of microorganisms. The facility failed to: Residents Affected - Some 1. Date, label, and sealed food items after there were opened and placed in the reach-in freezer. 2. Ensure the ready to eat deli meat was not stored in the same tray with thawing raw beef stew meat. 3. Ensure the deli meat dated 1/6/22 that exceeded storage period for deli meat per facility's policy was not stored in the refrigerator. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) which can lead to other serious medical complications and hospitalization for 41 out of the 48 residents who received food from the kitchen. Findings: During a concurrent observation and interview on January 18, 2022, at 8:44 a.m., with the dietary cook (Cook 1), in reach-in freezer 1 there was a bag with meat without a label to identify content or a date when it was placed for storage. [NAME] 1 stated it was a bag of beef fajitas. There was a bag of sausage links stored opened in the reach-in-freezer. In refrigerator 2 and 7 there were cartons of high-calorie protein shake in a medium plastic container without a label to indicated when it was thawed. [NAME] 1 did not recall why a bag of beef fajita was not labeled and who left open a bag of sausage links. [NAME] 1 stated high-calorie protein shakes were placed in the refrigerator yesterday. [NAME] 1 was observed to label the bag of beef fajita, tied the bag of sausage link, and placed labeled on the container for vanilla shake supplements dated 1/17/2022. [NAME] 1 stated high-calorie protein shake was good for one day after it was defrosted and it was for one resident in the facility who required one carton for each meal. A review of the label on high-calorie protein shake indicated store frozen with the manufacturer instructions to use within 14 days of thawing. During a concurrent observation and interview on January 18, 2022, at 8:54 a.m. with [NAME] 1, in small unit reach in refrigerator 3, there was observed a frozen stew cut beef dated 1/15/22 thawing on a tray together with the deli meat package dated 1/6/22. The thawing beef was noted with bloody juice running on the tray close to the deli meat package. The deli meat package was soft to touch. [NAME] 1 stated that the deli meat package was a turkey ham for sandwiches, and it was not raw. [NAME] 1 said there was no space in the refrigerator and that was why the deli meat was placed next to beef. [NAME] 1 verbalized that turkey ham is a raw poultry item and placed it refrigerator 3. During a review of the facility's policy and procedure titled Food preparation, dated 2018, indicated, to help ensure quality, foods which are prepared and not served on day of preparation are to be stored appropriately, covered, clearly identified, dated with the date of preparation and served within 24 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 27 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy and procedure titled Dietary-refrigerated storage, dated 01/2017, indicated all refrigerated foods should be properly covered. All cooked food must be labeled and dated. All frozen uncooked meat, poultry, and fish should be placed on the bottom shelf for proper thawing. A review of the facility's policy and procedure title Produce Storage Guidelines dated 2018, indicated maximum refrigeration time once meat has thawed for Luncheon meats, ham, bacon, frankfurters, and other processed meats was five days. A review of the 2017 U.S. Food and Drug Administration Food Code 302.12, except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, shall be identified with the common name of the food. A review of the 2017 U.S. Food and Drug Administration Food Code 3-302.11(A)(2), raw animal foods should be separated by type, cooking temperatures such that foods requiring a higher cooking temperature, like chicken, should be stored below or away from foods requiring a lower temperature, like pork and beef. In addition, raw animal foods should be spaced or placed in separate container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 28 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 11 of 29 resident rooms (Rooms 2, 4, 5, 7, 11, 12, 13, 14, 20, 26, 27) met the requirements of 80 square feet for each resident in multiple resident bedrooms. The 11 rooms consisted of two beds in each bedroom. This deficient practice had the potential to limit space to provide nursing care, and privacy for the residents. Findings: On 1/18/2022 at 2:00 p.m., during the Resident Council Meeting there were no concerns brought up regarding rooms. On 1/21/2022 at 2:35 p.m. during an interview with the Administrator (ADMIN), the ADMIN stated we have rooms that do not meet rooming requirements, the waiver was to accommodate residents with a room, the rooms do not have problems with space or quality. According to the Client Accommodations Analysis form dated 1/18/2022, indicated the facility had several rooms that measure less than the required 80 square footages per residents in multiple bedrooms. The letter indicated the needs of the residents are fully accommodated, they are able to move about freely, toilets and ample closet space are easily accessible, the facility is adequately equipped environmentally for comfort, and privacy of residents. The following resident bedrooms were: room [ROOM NUMBER] (2 beds) 153.4 room [ROOM NUMBER] (2 beds) 148.7 room [ROOM NUMBER] (2 beds) 158.12 room [ROOM NUMBER] (2 beds) 150.3 room [ROOM NUMBER] (2 beds) 150.3 room [ROOM NUMBER] (2 beds) 143.2 room [ROOM NUMBER] (2 beds) 158.12 room [ROOM NUMBER] (2 beds) 158.12 room [ROOM NUMBER] (2 beds) 158.6 room [ROOM NUMBER] (2 beds) 159.1 room [ROOM NUMBER] (2 beds) 141.9 On 1/18/2022 to 1/21/2022 during an observation of the facility and the resident's rooms, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 29 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm residents in the facility did not have difficulty getting in and out of their rooms. Each resident inside the affected rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The nursing staff had full access to provide treatment, administer medications, and assist residents to perform their individual routine and activities of daily living (ADLs, such as transferring, dressing, eating, and toileting). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 30 of 30