Health inspection·July 15, 2023

F 0688 1's joints (part of the body where two or more bones meet to allow movement) were normal and did not present with contractures. Level of Harm - Actual harm Residents Affected - Few A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPC), dated 2/14/2022 indicated Resident 1 did not present with contractures. A review of Resident 1's undated Restorative Nursing (a nurse with special training, skills, and knowledge in rehabilitative techniques) Orders (RNO), indicated Resident 1 was to receive AROM to both his upper extremities, every day five times a week or as tolerated beginning 3/23/2022. A review of Resident 1's Occupational Discharge Summary Evaluation (ODSE), dated 3/26/2022, indicated the restorative nursing program's (RNP) goal was to facilitate Resident 1 to maintain his current level of performance and prevent decline. A review of Resident 1's Physician's Telephone Order (TO), dated 7/27/2022 indicated Resident 1 was to receive AROM to his bilateral (both) upper extremities (BUE) every day, five times a week or as tolerated, by the RNA. During an observation on 7/11/2023, at 3:10 p.m., Resident 1 was observed lying in bed and his left hand was observed closed in fist. During an interview on 7/11/2023, at 3:10 p.m., Resident 1 stated he was currently bedridden (weak and unable to get out of bed) and needed help to get dressed and to pick up items because he could not straighten his fingers or grasp things with his left hand. Resident 1 stated, when he was admitted to the facility in 2022, he did not have any problems with his left hand but sometime last year (2022) he could no longer straighten his fingers on his left hand without using his right hand to straighten his fingers. Resident 1 stated, he felt frustrated because he could not use his left hand anymore like he used to. Resident 1 stated, it was painful whenever he tried to straighten the fingers in his left hand and the staff does not help him exercise his hands. During a concurrent observation and interview on 7/12/2023, at 12 p.m., with Resident 1, in the facility's dining room, Resident 1's left hand was observed resting on top of the dining room table, Resident 1's fingers of the hand were noted to be bent in a ball and Resident 1 was observed using only his right hand to eat. Resident 1 stated, he eats slower because he could only use his right hand and was unable to use his left hand to grasp the utensils, steady his plate or assist in anyway. A review of Resident 1's MDS, date 5/17/2023, indicated Resident 1's functional limitation in ROM was for his upper extremities was 0 (indicating no decline). A review of Resident 1's Occupational Therapist Evaluation and Plan of Treatment (OTEPT), dated 7/12/2023, indicated Resident 1 had a left-hand contracture. The OTEPT indicated Resident 1's ROM assessment of his left upper extremity indicated his left hand was impaired (moderate flexion [bent joint, cannot be straightened] with a contracture at the proximal interphalangeal ([PIP] finger joint) joint of the 3rd, 4th and 5th fingers of his left hand and a mild flexion contracture at PIP joint of the 1st finger of his left hand. A review of Resident 1's SBAR ([Situation Background Assessment Recommendation] a form of communication between members of a health care team, created after the concern was brought to the attention of the facility), dated 7/12/2023, indicated Resident 1's hand could not fully flex ([contract] to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 2 of 11 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 07/15/2023 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 0688 Level of Harm - Actual harm Residents Affected - Few shorten, become reduced in size) and extend (to straighten out). The SBAR indicated Resident 1 was unable to grasp objects easily with his left hand and experienced pain upon exercising his left hand. The SBAR indicated Resident 1's physician was notified and an order for Hydrocodone -Acetaminophen (a narcotic [a drug or other substance that affects mood or behavior] used to relieve moderate to severe pain) 10-325 milligrams ([mg] a unit of measurement), by mouth, once a day 30 minutes prior to RNA exercises. A review of Resident 1's Restorative Nursing Weekly Summaries (RNWS) indicated there was no documentation to show that Resident 1 received ROM therapy to his right and left hands, including his fingers, from 3/28/2023 through 7/11/2023. A review of Resident 1's Rehabilitation Screening Form, indicated the last screening was completed on 8/26/2022. A review of Resident 1's Joint Mobility Screening, indicated the last screening was completed on 5/18/2022. During an interview on 7/13/2023, at 9 a.m., the Director of Staff Development (DSD) stated, the RNA program falls under the direction of the nursing department. The DSD and the Director of Nursing (DON) were responsible for RNA skills training and ensuring RNA staff competencies were completed through a competency checklist. The DSD stated, the therapy department provides additional training to RNAs, but the facility does not maintain records of the RNAs competencies. During an interview on 7/13/2023, at 9:35 a.m., RNA 2 stated, she did not perform ROM exercises on any Residents' hands unless there was a specific order from the doctor or if the residents had a splint (an appliance made of different materials for the fixation [the action of making something firm or stable], union or protection of an injured part of the body) RNA 2 stated, Resident 1 had orders for AROM on his B (both) UEs but that did not include his hands. During an interview on 7/13/2023, at 9:57 a.m., RNA 1 stated, AROM exercises to the upper extremities meant for them (RNAs) to direct and observe the resident while they (the residents) exercised their shoulders, elbows, and forearms independently. RNA 1 stated, AROM did not include exercising of the hands, unless there was an order to that indicated specifically to exercise hands. RNA 1 stated, if there was a change in residents' ROM, they (RNAs) were instructed to inform the charge nurse and staff in the therapy department. During a concurrent record review and interview, on 7/13/2023 at 10:30 a.m., with the DSD, the Certified Nursing Assistant Skills, and Competency Validation (CV) for RNA 1, dated 9/1/2015, RNA 2, dated 7/22/2021, and RNA 3, dated 7/29/2019 were reviewed. During a concurrent record review and interview on 7/14/2023, at 11:46 a.m., with the Physical Therapy Regional Director (PTRD), Resident 1's Restorative Nursing Program Referral Care Plan (RNP-CP), dated 3/23/2022 was reviewed. The PTRD stated, the RNA-CP indicated Resident 1 was discharged from physical and occupational therapy on 3/23/2022 and was at risk for weakness to his BUEs. The PTRD stated the RNP-CP's goal was for Resident 1 to maintain ROM and strength to all of his extremities and orders on the RNP-CP for Resident 1 to receive AROM exercises to his BUEs, daily, five time per week or as tolerated. The PTRD stated AROM means Resident 1 would perform ROM exercises independently without physical assistance from the RNA, but the RNA would direct and observe Resident 1 for any pain, discomfort, or limitations as he (Resident 1) performed the ROM exercises. The PTRD stated, BUEs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 3 of 11 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 07/15/2023 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 0688 Level of Harm - Actual harm Residents Affected - Few are defined as shoulders, arms, elbows, wrists, hands, and all fingers to both left and right side of the body. The PTRD stated, if AROM exercises were not performed as ordered, the RNAs might not observe a decline in the resident's function and the resident would be at risk for a decline in their ROM. During an interview on 7/14/2023, at 1:30 p.m., RNA 3 stated, during AROM exercises to resident's upper extremities he directs and observes as they (the resident) exercise their shoulders, elbows, and forearms. RNA 3 stated, AROM of the upper extremities does not include hands and fingers, unless there is an order from the physician that indicates to exercise the resident's hands and fingers. RNA 3 stated he received training from RNA 1 and sometimes a physical therapist would train him during resident hand off (when a resident is discharged from physical and/or occupational therapy and received by the RNP). During a concurrent record review and interview on 7/14/2023, at 4 p.m., with the Registered Occupational Therapist (ROT), Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OTEPT), dated 2/14/2022 was reviewed. The ROT stated Resident 1's OTEPT indicated Resident 1's left hand's ROM was within functional limits ([WFL] within what is considered normal movement for that joint), meaning Resident 1 was able to use his left hand to pick up items and accomplish daily tasks at that time. The ROT stated, Resident 1's current OTEPT, dated 7/12/2023, indicated a moderate contracture (26-50% loss in ROM) to his 3rd, 4th, 5th PIP joint and a mild flexion contracture at his 1st finger PIP joint was noted. The ROT stated, she was the therapist who performed Resident 1's OT evaluation on 7/12/2023. The ROT stated, Resident 1 could not straighten the fingers on his left hand which demonstrated a decline in Resident 1's ROM in comparison to the OT evaluation on 7/14/2022. A review of the facility's job description (JD) for RNAs, dated 11/2014, indicated the RNA is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. The RNAs JD included following general duties and responsibilities, recording on flow sheets, notes and charts when applicable, reporting significant changes in the resident's condition to the licensed vocational nurse (LVN)/registered nurse (RN) as soon as practical, providing range of motion and general strengthening exercises, documenting daily and weekly on residents in the restorative program, reports, charts, and communicates to occupation therapy any observed problems or any changes in the residents condition, motivation level, mobility level and resident complaints of pain. A review of the facility's Policy and Procedure (P/P) titled, Limitations in Range of Motion and Mobility and Referrals for Therapy, revised 10/2017, indicated a resident who enters the facility without limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates that the reduction in range of motion is unavoidable. The facility will ensure that ongoing communication and caregiver training takes place between the Restorative Nursing Assistants (RNA) and the therapy department. Upon admission and quarterly, the appropriate therapy department will screen residents unless there is a physician's order upon admission for therapy evaluations. If the resident receives rehabilitation services and it is determined that the resident is to be referred for RNA services at the completion of the therapy, the appropriate referral form will be completed by the therapist and the therapy department will provide caregiver training to the RNA. The RNA and the therapist providing the training will both sign the appropriate form to document the training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 4 of 11 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 07/15/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure restorative nursing aides ([RNA] provides rehabilitative care to individuals recovering from illnesses or injuries) had skill sets necessary to provide active range of motion ([AROM] movement at a given joint when the person moves voluntarily) to the left and right upper extremities (upper arm, forearm, wrist, hand and fingers and thumb) for one of three sampled residents (Resident 1) as prescribed in the resident's care plan and physician's orders to prevent decrease in ROM for one of three sample residents (Resident 1) from 3/28/2022 through 7/11/2023. This deficient practice resulted in Resident 1 developing a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) to his left hand, pain upon movement of his left hand, the inability to fully straighten the 1st, 3rd, 4th, and 5th fingers of his left hand or use his left hand as needed to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). Findings: A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial infection of the skin), a fracture (a break) of the right toe, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of the right ankle and foot. A review of the facility's undated Resident Census (record of hospitalizations, room changes, and payer source changes), indicated Resident 1 remained in the facility since his admission on [DATE] to present with no hospitalizations. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/12/2022, indicated Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 1 required extensive one-person physical assist for bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene and limited one-person physical assist when bathing. The MDS indicated Resident 1 had no functional limitations in the ROM to both of his arms. A review of the Resident 1's History and Physical (H&P), dated 2/9/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Nursing admission Assessment (NAA), dated 2/12/2022, indicated Resident 1's joints were normal and did not present with contractures. A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPC), dated 2/14/2022 indicated Resident 1 did not present with contractures. A review of Resident 1's undated Restorative Nursing Orders (RNO), indicated Resident 1 was to receive AROM every day five times a week or as tolerated beginning 3/23/2022. A review of Resident 1's Occupational Discharge Summary Evaluation (ODSE), dated 3/26/2022, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 5 of 11 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 07/15/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated the restorative nursing program's (RNP) goal was to facilitate Resident 1 to maintain his current level of performance and prevent decline. A review of Resident 1's Physician's Telephone Order (TO), dated 7/27/2022 indicated Resident 1 was to receive AROM to his bilateral (both) upper extremities (BUE) every day, five times a week or as tolerated, by the RNA. During an observation on 7/11/2023, at 3:10 p.m., Resident 1 was observed lying in bed and his left hand was observed closed, making a fist. During a subsequent interview on 7/11/2023, at 3:10 p.m., Resident 1 stated he was currently bedridden (weak and unable to get out of bed) and needed help to get dressed and to pick up items because he could not straighten his fingers or grasp things with his left hand. Resident 1 stated, when he was admitted to the facility in 2022, he did not have any problems with his left hand but sometime last year (2022) he could no longer straighten his fingers on his left hand without using his right hand to straighten his fingers. Resident 1 stated, he felt frustrated because he could not use his left hand anymore like he used to. Resident 1 stated, it was painful whenever he tried to straighten the fingers in his left hand and the staff does not help him exercise his hands. During a concurrent observation and interview on 7/12/2023, at 12 p.m., with Resident 1, in the facility's dining room, Resident 1's left hand was observed resting on top of the dining room table, Resident 1's fingers of the hand were noted to be bent in a ball and Resident 1 was observed using only his right hand to eat. Resident 1 stated, he eats slower because he could only use his right hand and was unable to use his left hand to grasp the utensils, steady his plate or assist in anyway. A review of Resident 1's Occupational Therapist Evaluation and Plan of Treatment (OTEPT), dated 7/12/2023, indicated Resident 1 had a left-hand contracture. The OTEPT indicated Resident 1's ROM assessment of his left upper extremity indicated his left hand was impaired (moderate flexion [bent joint, cannot be straightened] with a contracture at the proximal interphalangeal ([PIP] finger joint) joint of the 3rd, 4th and 5th fingers of his left hand and a mild flexion contracture at PIP joint of the 1st finger of his left hand. A review of Resident 1's SBAR ([Situation Background Assessment Recommendation] a form of communication between members of a health care team, created after the concern was brought to the attention of the facility), dated 7/12/2023, indicated Resident 1's hand could not fully flex ([contract] to shorten, become reduced in size) and extend (to straighten out). The SBAR indicated Resident 1 was unable to grasp objects easily with his left hand and experienced pain upon exercising his left hand. The SBAR indicated Resident 1's physician was notified and an order for Hydrocodone -Acetaminophen (a narcotic [a drug or other substance that affects mood or behavior] use for moderate to severe pain relief) 10-325 mg by mouth once a day 30 minutes prior to RNA exercises. A review of Resident 1's Restorative Nursing Weekly Summaries (RNWS) indicated Resident 1 did not receive ROM therapy to his right and left hands, including his fingers, from 3/28/2023 through 7/11/2023. During an interview on 7/13/2023, at 9 a.m., the Director of Staff Development (DSD) stated, the RNA program falls under the direction of the nursing department. The DSD and the Director of Nursing (DON) were responsible for RNA skills training and ensuring RNA staff competencies were completed through a competency checklist. The DSD stated, the therapy department provides additional training to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 6 of 11 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 07/15/2023 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 0726 RNAs, but the facility does not maintain records of the RNAs competencies. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/13/2023, at 9:35 a.m., RNA 2 stated, she did not perform ROM exercises on Residents' hands unless there was a specific order from the doctor or if the residents had a splint. RNA 2 stated, Resident 1 had orders for AROM on his BUEs but that did not include his hands. Residents Affected - Some During an interview on 7/13/2023, at 9:57 a.m., RNA 1 stated, AROM exercises to the upper extremities meant for them (RNAs) to direct and observe the resident while they (the residents) exercised their shoulders, elbows, and forearms independently. RNA 1 stated, AROM did not include exercising of the hands, unless there was an order to that indicated specifically to exercise hands. RNA 1 stated, if there was a change in residents' ROM, they (RNAs) were instructed to inform the charge nurse and staff in the therapy department. RNA 1 stated, she received training on how to perform ROM exercises from the previous Director of Rehabilitation (DOR) who no longer worked at the facility. During a concurrent record review and interview, on 7/13/2023 at 10:30 a.m., with the DSD, the Certified Nursing Assistant Skills, and Competency Validation (CV) for RNA 1, dated 9/1/2015, RNA 2, dated 7/22/2021, and RNA 3, dated 7/29/2019 were reviewed. The CV did not list ROM as one of the competencies for RNAs. The DSD stated, according to the CV RNA 1, RNA 2 and RNA 3's competencies were not validated for ROM. The DSD stated, not ensuring RNAs were competent in performing ROM could result in residents not receiving effective ROM therapy which could cause a functional decline to resident's joints. During a concurrent record review and interview on 7/14/2023, at 11:46 a.m., with the Physical Therapy Regional Director (PTRD), Resident 1's Restorative Nursing Program Referral Care Plan (RNP-CP), dated 3/23/2022 was reviewed. The PTRD stated, the RNA-CP indicated Resident 1 was discharged from physical and occupational therapy on 3/23/2022 to the restorative nursing program and was at risk for weakness to his BUEs. The PTRD stated the RNP-CP's goal was for Resident 1 to maintain ROM and strength to all of his extremities and orders on the RNP-CP was for Resident 1 to receive AROM exercises to his BUEs, daily, five time per week or as tolerated. The PTRD stated BUEs are defined as shoulders, arms, elbows, wrists, hands, and all fingers to both left and right side of the body. The PTRD stated, if AROM exercises were not performed as ordered, the RNAs might not observe a decline in the resident's function and the resident would be at risk for a decline in their ROM. During an interview on 7/14/2023, at 1:30 p.m., RNA 3 stated, during AROM exercises to resident's upper extremities he directs and observes as they (the resident) exercise their shoulders, elbows, and forearms. RNA 3 stated, AROM of the upper extremities does not include hands and fingers, unless there is an order from the physician that indicates to exercise the resident's hands and fingers. RNA 3 stated he received training from RNA 1 and sometimes a physical therapist would train him during resident hand off (when a resident is discharged from physical and/or occupational therapy and received by the RNP). During a concurrent record review and interview on 7/14/2023, at 4 p.m., with the Registered Occupational Therapist (ROT), Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OTEPT), dated 2/14/2022 was reviewed. The ROT stated Resident 1's OTEPT indicated Resident 1's left hand's ROM was within functional limits ([WFL] within what is considered normal movement for that joint), meaning Resident was able to use his left hand to pick up items and accomplish daily tasks at that time. The ROT stated, Resident 1's current OTEPT, dated 7/12/2023, indicated a moderate contracture (26-50% loss in ROM) to his 3rd, 4th, 5th PIP joint and a mild flexion contracture at his 1st finger PIP joint was noted. The ROT stated, she was the therapist who performed Resident 1's OT evaluation on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 7 of 11 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 07/15/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7/12/2023. The ROT stated, Resident 1 could not straighten the fingers on his left hand which demonstrated a decline in Resident 1's ROM in comparison to the OT evaluation on 7/14/2022. A review of the facility's job description (JD) for RNAs, dated 11/2014, indicated the RNA is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. The RNAs JD included following general duties and responsibilities, recording on flow sheets, notes and charts when applicable, reporting significant changes in the resident's condition to the LVN/RN as soon as practical, providing range of motion and general strengthening exercises, documenting daily and weekly on residents in the restorative program, reports, charts, and communicates to occupation therapy any observed problems or any changes in the residents condition, motivation level, mobility level and resident complaints of pain. Motion and Mobility and Referrals for Therapy, revised 10/2017, indicated a resident who enters the facility without limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates that the reduction in range of motion is unavoidable. The facility will ensure that ongoing communication and caregiver training takes place between the Restorative Nursing Assistants (RNA) and the therapy department. Upon admission and quarterly, the appropriate therapy department will screen residents unless there is a physician's order upon admission for therapy evaluations. If the resident receives rehabilitation services and it is determined that the resident is to be referred for RNA services at the completion of the therapy, the appropriate referral form will be completed by the therapist and the therapy department will provide caregiver training to the RNA Th RNA and the therapist providing the training will both sign the appropriate form to document the training. Based on observation, interview, and record review, the facility failed to ensure restorative nursing aides ([RNA] provides rehabilitative care to individuals recovering from illnesses or injuries) had skill sets necessary to provide active range of motion ([AROM] movement at a given joint when the person moves voluntarily) to the left and right upper extremities (upper arm, forearm, wrist, hand and fingers and thumb) for one of three sampled residents (Resident 1) as prescribed in the resident's care plan and physician's orders to prevent decrease in ROM for one of three sample residents (Resident 1) from 3/28/2022 through 7/11/2023. This deficient practice resulted in Resident 1 developing a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) to his left hand, pain upon movement of his left hand, the inability to fully straighten the 1st, 3rd, 4th, and 5th fingers of his left hand or use his left hand as needed to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). Findings: A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial infection of the skin), a fracture (a break) of the right toe, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of the right ankle and foot. A review of the facility's undated Resident Census (record of hospitalizations, room changes, and payer source changes), indicated Resident 1 remained in the facility since his admission on [DATE] to present with no hospitalizations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 8 of 11 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 07/15/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/12/2022, indicated Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 1 required extensive one-person physical assist for bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene and limited one-person physical assist when bathing. The MDS indicated Resident 1 had no functional limitations in the ROM to both of his arms. A review of the Resident 1's History and Physical (H&P), dated 2/9/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Nursing admission Assessment (NAA), dated 2/12/2022, indicated Resident 1's joints were normal and did not present with contractures. A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPC), dated 2/14/2022 indicated Resident 1 did not present with contractures. A review of Resident 1's undated Restorative Nursing Orders (RNO), indicated Resident 1 was to receive AROM every day five times a week or as tolerated beginning 3/23/2022. A review of Resident 1's Occupational Discharge Summary Evaluation (ODSE), dated 3/26/2022, indicated the restorative nursing program's (RNP) goal was to facilitate Resident 1 to maintain his current level of performance and prevent decline. A review of Resident 1's Physician's Telephone Order (TO), dated 7/27/2022 indicated Resident 1 was to receive AROM to his bilateral (both) upper extremities (BUE) every day, five times a week or as tolerated, by the RNA. During an observation on 7/11/2023, at 3:10 p.m., Resident 1 was observed lying in bed and his left hand was observed closed, making a fist. During a subsequent interview on 7/11/2023, at 3:10 p.m., Resident 1 stated he was currently bedridden (weak and unable to get out of bed) and needed help to get dressed and to pick up items because he could not straighten his fingers or grasp things with his left hand. Resident 1 stated, when he was admitted to the facility in 2022, he did not have any problems with his left hand but sometime last year (2022) he could no longer straighten his fingers on his left hand without using his right hand to straighten his fingers. Resident 1 stated, he felt frustrated because he could not use his left hand anymore like he used to. Resident 1 stated, it was painful whenever he tried to straighten the fingers in his left hand and the staff does not help him exercise his hands. During a concurrent observation and interview on 7/12/2023, at 12 p.m., with Resident 1, in the facility's dining room, Resident 1's left hand was observed resting on top of the dining room table, Resident 1's fingers of the hand were noted to be bent in a ball and Resident 1 was observed using only his right hand to eat. Resident 1 stated, he eats slower because he could only use his right hand and was unable to use his left hand to grasp the utensils, steady his plate or assist in anyway. A review of Resident 1's Occupational Therapist Evaluation and Plan of Treatment (OTEPT), dated 7/12/2023, indicated Resident 1 had a left-hand contracture. The OTEPT indicated Resident 1's ROM assessment of his left upper extremity indicated his left hand was impaired (moderate flexion [bent joint, cannot be straightened] with a contracture at the proximal interphalangeal ([PIP] finger joint) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 9 of 11 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 07/15/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some joint of the 3rd, 4th and 5thfingers of his left hand and a mild flexion contracture at PIP joint of the 1stfinger of his left hand. A review of Resident 1's SBAR ([Situation Background Assessment Recommendation] a form of communication between members of a health care team, created after the concern was brought to the attention of the facility), dated 7/12/2023, indicated Resident 1's hand could not fully flex ([contract] to shorten, become reduced in size) and extend (to straighten out). The SBAR indicated Resident 1 was unable to grasp objects easily with his left hand and experienced pain upon exercising his left hand. The SBAR indicated Resident 1's physician was notified and an order for Hydrocodone -Acetaminophen (a narcotic [a drug or other substance that affects mood or behavior] use for moderate to severe pain relief) 10-325 mg by mouth once a day 30 minutes prior to RNA exercises. A review of Resident 1's Restorative Nursing Weekly Summaries (RNWS) indicated Resident 1 did not receive ROM therapy to his right and left hands, including his fingers, from 3/28/2023 through 7/11/2023. During an interview on 7/13/2023, at 9 a.m., the Director of Staff Development (DSD) stated, the RNA program falls under the direction of the nursing department. The DSD and the Director of Nursing (DON) were responsible for RNA skills training and ensuring RNA staff competencies were completed through a competency checklist. The DSD stated, the therapy department provides additional training to RNAs, but the facility does not maintain records of the RNAs competencies. During an interview on 7/13/2023, at 9:35 a.m., RNA 2 stated, she did not perform ROM exercises on Residents' hands unless there was a specific order from the doctor or if the residents had a splint. RNA 2 stated, Resident 1 had orders for AROM on his BUEs but that did not include his hands. During an interview on 7/13/2023, at 9:57 a.m., RNA 1 stated, AROM exercises to the upper extremities meant for them (RNAs) to direct and observe the resident while they (the residents) exercised their shoulders, elbows, and forearms independently. RNA 1 stated, AROM did not include exercising of the hands, unless there was an order to that indicated specifically to exercise hands. RNA 1 stated, if there was a change in residents' ROM, they (RNAs) were instructed to inform the charge nurse and staff in the therapy department. RNA 1 stated, she received training on how to perform ROM exercises from the previous Director of Rehabilitation (DOR) who no longer worked at the facility. During a concurrent record review and interview, on 7/13/2023 at 10:30 a.m., with the DSD, the Certified Nursing Assistant Skills, and Competency Validation (CV) for RNA 1, dated 9/1/2015, RNA 2, dated 7/22/2021, and RNA 3, dated 7/29/2019 were reviewed. The CV did not list ROM as one of the competencies for RNAs. The DSD stated, according to the CV RNA 1, RNA 2 and RNA 3's competencies were not validated for ROM. The DSD stated, not ensuring RNAs were competent in performing ROM could result in residents not receiving effective ROM therapy which could cause a functional decline to resident's joints. During a concurrent record review and interview on 7/14/2023, at 11:46 a.m., with the Physical Therapy Regional Director (PTRD), Resident 1's Restorative Nursing Program Referral Care Plan (RNP-CP), dated 3/23/2022 was reviewed. The PTRD stated, the RNA-CP indicated Resident 1 was discharged from physical and occupational therapy on 3/23/2022 to the restorative nursing program and was at risk for weakness to his BUEs. The PTRD stated the RNP-CP's goal was for Resident 1 to maintain ROM and strength to all of his extremities and orders on the RNP-CP was for Resident 1 to receive AROM exercises to his BUEs, daily, five time per week or as tolerated. The PTRD stated BUEs are defined as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 10 of 11 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 07/15/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shoulders, arms, elbows, wrists, hands, and all fingers to both left and right side of the body. The PTRD stated, if AROM exercises were not performed as ordered, the RNAs might not observe a decline in the resident's function and the resident would be at risk for a decline in their ROM. During an interview on 7/14/2023, at 1:30 p.m., RNA 3 stated, during AROM exercises to resident's upper extremities he directs and observes as they (the resident) exercise their shoulders, elbows, and forearms. RNA 3 stated, AROM of the upper extremities does not include hands and fingers, unless there is an order from the physician that indicates to exercise the resident's hands and fingers. RNA 3 stated he received training from RNA 1 and sometimes a physical therapist would train him during resident hand off (when a resident is discharged from physical and/or occupational therapy and received by the RNP). During a concurrent record review and interview on 7/14/2023, at 4 p.m., with the Registered Occupational Therapist (ROT), Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OTEPT), dated 2/14/2022 was reviewed. The ROT stated Resident 1's OTEPT indicated Resident 1's left hand's ROM was within functional limits ([WFL] within what is considered normal movement for that joint), meaning Resident was able to use his left hand to pick up items and accomplish daily tasks at that time. The ROT stated, Resident 1's current OTEPT, dated 7/12/2023, indicated a moderate contracture (26-50% loss in ROM) to his 3rd, 4th, 5thPIP joint and a mild flexion contracture at his 1st finger PIP joint was noted. The ROT stated, she was the therapist who performed Resident 1's OT evaluation on 7/12/2023. The ROT stated, Resident 1 could not straighten the fingers on his left hand which demonstrated a decline in Resident 1's ROM in comparison to the OT evaluation on 7/14/2022. A review of the facility's job description (JD) for RNAs, dated 11/2014, indicated the RNA is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. The RNAs JD included following general duties and responsibilities, recording on flow sheets, notes and charts when applicable, reporting significant changes in the resident's condition to the LVN/RN as soon as practical, providing range of motion and general strengthening exercises, documenting daily and weekly on residents in the restorative program, reports, charts, and communicates to occupation therapy any observed problems or any changes in the residents condition, motivation level, mobility level and resident complaints of pain. A review of the facility's Policy and Procedure (P/P) titled, Limitations in Range of Motion and Mobility and Referrals for Therapy, revised 10/2017, indicated a resident who enters the facility without limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates that the reduction in range of motion is unavoidable. The facility will ensure that ongoing communication and caregiver training takes place between the Restorative Nursing Assistants (RNA) and the therapy department. Upon admission and quarterly, the appropriate therapy department will screen residents unless there is a physician's order upon admission for therapy evaluations. If the resident receives rehabilitation services and it is determined that the resident is to be referred for RNA services at the completion of the therapy, the appropriate referral form will be completed by the therapist and the therapy department will provide caregiver training to the RNA Th RNA and the therapist providing the training will both sign the appropriate form to document the training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 11 of 11