Health inspection·February 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because purpose of the dignity bag was to protect the resident's privacy and dignity. CNA 1 stated by not having a dignity bag, Resident 1's dignity and privacy could be compromised. During an interview with the Director of Nursing (DON) on 2/25/2024 at 2:42 p.m., the DON stated urinary bags are supposed to have a dignity bag. The DON stated the purpose of the dignity bag was to improve the resident's dignity, quality of life and privacy. The DON stated if the urinary bag did not have a dignity bag around it, other people can see the urinary bag and that could compromise the resident's privacy and dignity. During a review of the facility's policy and procedure (P&P) titled Resident's Right to Dignity and Privacy, dated 9/2017, the P&P indicated staff shall promote dignity and assist residents by helping the resident keep urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 2 of 18 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 02/25/2024 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 assess the urine in the foley catheter tubing (a plastic device inserted inside the body to drain urine from the bladder [an organ that is part of the urinary system] into an outside bag) for sediments and cloudiness for one of two sampled residents (Resident 8). Resident 8 had an indwelling foley catheter with noticeable sediment (accumulation of white blood cells) and cloudiness in the urine tubing. This deficient practice placed Resident 8 at risk for a urinary tract infection ([UTI] when bacteria enter the urinary system and infect the urinary tract). Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted on [DATE] and readmitted on [DATE], with diagnoses that included Benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland [a part of the urinary system], retention of urine unspecified (inability to completely empty the bladder of urine), and disorder of kidney and ureter unspecified (kidney tissue damage). During a review of Resident 8's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 1/24/2024, the MDS indicated Resident 8's cognitive skills (thought process) was independent -decisions consistent/reasonable. The MDS indicated Resident 8 required dependent assistance with activities of daily living such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 8's physician's orders dated 2/1/2024, the physician's orders indicated Resident 8 had an order for an Indwelling urinary foley catheter FR 16/10ml (French catheter size 16/10 millimeter of normal saline balloon capacity), for Urinary Retention. The physician order indicated, to monitor urine for color, odor and sediments every shift. During a review of Resident 8's untitled care plan for Foley Catheter dated 1/1/2024, the care plan indicated Resident 8 was at risk for recurrent UTI, will be minimized daily. Resident 8's care plan interventions indicated to observe urine for signs and symptoms of infection such as foul odor, abnormal urine color, presence of sediments, or blood and notify MD promptly. During a concurrent observation and interview on 2/24/2024 at 1:43p.m., in Resident 8's room. Resident 8 was observed with a foley catheter . Resident 8's foley catheter tubing was draining urine with sediments and cloudiness. The Treatment Nurse (TN) observed the foley catheter with sediments and cloudiness in the tubing. During a concurrent observation and interview on 2/24/2024 at 2:29 p.m., with Licensed Vocational Nurse (LVN) 1 LVN 1 stated, yes, there are sediments in foley catheter tubing. LVN 1 stated, the foley needed to be assessed everyday to prevent infections. LVN 1 stated, nurses assess the catheter for urine color, sediment, and any blood. LVN 1 stated, when there are sediments, we need to inform the doctor because it could be a symptom of a UTI and we monitor for signs and symptoms of infections. LVN 1 stated, it is extremely important to prevent infections and lower risk of getting a UTI. LVN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 3 of 18 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 02/25/2024 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 stated, I failed to observe the foley catheter this morning. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/25/2024 at 1:34 p.m., with the Registered Nurses (RN) the RN stated, when residents are admitted to the facility with a foley catheter, nurses assess the type and size of foley catheter. The RN stated, nurses assess for any odor or cloudiness, and that the drainage bag is below the bladder and covered with a privacy bag. The RN stated, the foley catheter needs to be assessed when nurses do, their daily rounds. The RN stated, if there is cloudiness or the urine has an amber color, we notify the doctor for and order to check for UTI or infection. The RN stated, if the catheter is kept without addressing the cloudiness, it can lead to infection, sepsis, and further complications. The RN stated nurses are resident advocate and are responsible in residents' safety. Residents Affected - Few During an interview on 2/25/2024 at 1:36 p.m., with the Director of Nursing (DON), the DON stated, when nurses do rounds in the morning, the foley catheter is assessed for cloudiness, and color of the urine. The DON stated, if there are any concerns, the nurses must notify the doctor. The DON stated, if nurses ignore the urine sediments in a catheter, it will put the Resident at risk of developing a UTI. The DON stated, a UTI can affect the resident's mental status causing confusion. The DON stated, it is our responsibility to prevent any UTI in residents. During a review of the facility's policies and procedures (P&P) titled Indwelling Catheter Care, dated 3/2021the P&P indicated Abnormal urine characteristics (i.e., foul odor, dark concentrated urine) should be documented in the nurses' notes. Inform the physician, as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 4 of 18 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 02/25/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 two of two sampled residents (Resident 14 and Resident 103) received respiratory care consistent with professional standards of practice when: Residents Affected - Few 1.Resident 14's oxygen (life sustaining gas in air) nasal cannula (a device used to deliver supplemental oxygen) tubing, and humidifier (liquid that moistens the air) bottle was not labeled with the date of change to be used as reference for changing humidifier bottles every seven days. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, and/or hospitalization for Resident 14 . 2.Resident 103's Bilevel positive airway pressure (BIPAP - a device that helps a patient breath) machine was not set up for Resident 103's use, as ordered by physician. This deficient practice had the potential to result in Resident 103 being unable to breathe comfortably, and/or hospitalization. Findings: During a review of Resident 14's admission Record, dated 2/25/2024, the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and last admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic kidney disease ([CKD], condition which the kidneys are damaged and cannot filter blood as well as they should), and type 2 diabetes mellitus (abnormal blood sugar). During a review of Resident 14's history and physical (H&P), dated 9/25/2023, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/29/2023, the MDS indicated Resident 14 was able to understand and be understood by others. The MDS indicated Resident 14 required set up assistance from staff for activities of daily living (ADLs) such as eating and oral hygiene and required supervision assistance from staff for personal hygiene, toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear. During a review of Resident 14's order summary report (MD orders), dated 2/25/2024, the MD orders indicated an order dated 2/18/2024 for oxygen at 3 L/min as needed. During a concurrent observation and interview on 2/24/2024 at 2:51 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 14's room, the oxygen tubing and humidification bottle had no date of last time changed. LVN 2 stated oxygen tubing and humidification bottle should have a date on the tubing and bottle. LVN 2 stated tubing and humidification bottle should be changed and dated once a week and when needed. LVN 2 stated the resident could potentially get an infection, by being exposed to germs. LVN 2 stated checking the tubing should be done by all licensed personnel upon first entering the resident's room. During an interview on 2/25/2024 at 3:30 p.m. with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 5 of 18 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 02/25/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tubing, humidifier, and the bag tubing should be dated. The DON stated if there is not a date of when it was las changed, staff would not know when it is due for change. The DON stated this could potentially cause upper respiratory infections, this is an infection control issue. During a review of the facility's policy and procedure (P&P) titled, Oxygen Equipment, (undated), the P&P indicated, The following is the procedure for oxygen equipment. Pre-filled humidifiers are to be dated and replaced ever week. Tubing should be replaced every week. Cannulas should be replaced every week. During a review of Resident 103's admission Record, dated 2/25/2024, the admission Record indicated Resident 103 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypercapnia (high levels of byproduct of respiration built up in the blood), obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep). During a review of Resident 103's H&P, dated 2/22/2024, the H&P indicated Resident 103 had the capacity to understand and make decisions. During a review of Resident 103's MDS, dated [DATE], the MDS indicated Resident 103 was able to understand and be understood by others. The MDS indicated Resident 103 required partial assistance from staff for ADLs such as oral hygiene and personal hygiene, toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear. During an interview on 2/24/2024 at 1:41 p.m. with Resident 103, Resident 103 stated since returning from the hospital on 2/14/2024 I have not had my BIPAP machine. During a concurrent observation and interview on 2/25/2024 at 7:58 a.m. with Infection Preventionist Nurse (IPN) 1 in Resident 103's room, there was no BIPAP machine set up in resident 103's room. IPN 1 stated there is no BIPAP machine set up in his room. During a subsequent concurrent interview and record review 2/25/2024 at 7:58 a.m. with IPN 1, Resident 103's physician orders dated 2/15/2024 was reviewed. The physician orders dated 2/15/2024 indicated for a BIPAP machine at hour of sleep as needed, was ordered for Resident 103. IPN 1 stated Resident 103's BIPAP order should have been followed up on. IPN 1 stated that not having access to the BIPAP machine can affect Resident 103 by not getting the proper assistance breathing from the BIPAP during hours of sleep. IPN 1 stated by not getting enough air exchange can potentially affect the mental status, decreased energy levels, it can cause lethargy, and shortness of breath. During a subsequent interview on 2/25/2024 at 3:30 p.m. with the Director of Nursing (DON,) the DON stated it is necessary to implement the physician's order for the resident to recover or maintain their health. The DON stated if you don't follow the physician's order it could be be detrimental to the resident's health. The DON stated not following the physician order for the BIPAP machine for Resident 103 could potentially cause respiratory distress, change in level of consciousness, weakness. During a record review of the facility's policy and procedure (P&P) titled Physician Services and Orders dated 1/2017, the P&P indicated must provide orders for the resident's immediate care and needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 6 of 18 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 02/25/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs three of 11 sampled residents (Resident 29, 32 and 202): 1. Resident 29 and Resident 32 did not receive medication at the scheduled time and with food as ordered by the physician. 2. Resident 202 received a crushed enteric coated medication. These deficient practices had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered. Findings: During a review of Resident 32's admission Record, dated 2/25/2024, the admission record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including hypertension (when the pressure in your blood vessels is too high), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). During a review of Resident 32's history and physical (H&P), dated 4/8/2023, the H&P indicated Resident 32 was able to make decisions for activities of daily living. During a review of Resident 32's order summary report (MD orders), dated 2/25/2024, the MD orders indicated there was an order starting from 2/10/2023 for metoprolol tartrate (medication for high blood pressure) 50mg with meals. During an observation on 2/24/2024 at 9:01 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 administered Metoprolol to Resident 32 without a meal or snacks. During an interview on 2/24/2024 at 3:02 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 32's medication metoprolol tartrate was to be given with food at 7:15 a.m. LVN 1 stated Resident 32 ate breakfast about 7:30 a.m. LVN 1 stated yes, the medication was given late, it was given around 9:50 a.m. During a review of Resident 29's admission Record, dated 2/25/2024, the admission record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart does not pump blood effectively), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining) and hypertension (when the pressure in your blood vessels is too high). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 7 of 18 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 02/25/2024 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 During a review of Resident 29's history and physical (H&P), dated 6/1/2023, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's order summary report (MD orders), dated 2/25/2024, the MD orders indicated there was an order starting from 10/22/2022 for metformin HCl (medication used to treat diabetes [abnormal sugar]) tablet 500milligrams (mg - a unit of measure for mass) one time a day take with food. During a review of Resident 29's medication administration record (MAR), dated 2/1/2024-2/29/2024, the MAR indicated metformin HCL was to be given at 7:30 a.m. with food. During an observation on 2/24/2024 at 9:50 a.m. with LVN 1 at med cart 1, LVN 1 administered metformin to Resident 29 without a meal or snacks. During a subsequent interview on 2/24/2024 at 3:02 p.m. with LVN 1, LVN 1 stated Resident 29's medication Metformin HCL was to be given with food at 7:30 a.m. LVN stated Resident 29 ate breakfast about 7:30 a.m. LVN 1 stated yes, medication was given late, it was given around 9:00 a.m. LVN stated it is important to give medication on time to keep everything on balance. LVN 1 stated if giving without food it could potentially cause medication to be less effective, stomach issues. LVN 1 stated it is important to follow doctor orders. During a review of Resident 202's admission Record, dated 2/25/2024, the admission record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness characterized by extreme mood swings), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 202's history and physical (H&P), dated 2/24/2024, the H&P indicated Resident 202 had the capacity to understand and make decisions. The H&P indicated diagnoses including hypertension (when the pressure in your blood vessels is too high). During a review of Resident 202's order summary report (MD orders), dated 2/25/2024, the MD orders indicated there was an order starting from 2/10/2023 for metoprolol succinate (medication for high blood pressure) extended release (ER-designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) 24hour 50mg. During an observation on 2/24/2024 at 9:19 a.m. with LVN 1, LVN 1 crushed and administered metoprolol extended release to Resident 202. During an interview on 2/25/2024 at 9:52 a.m. with Registered Nurse (RN) 1, RN 1 stated that if medication is supposed to be given with meals and not it could potentially cause stomach issues. RN 1 stated an extended-release medication should not be crushed. RN 1 stated it is about the timing and the way it absorbs into the system. RN 1 stated if medication is crushed it could potentially be ineffective. RN 1 stated if medications are given late the condition the medication is used for can be uncontrolled. RN 1 stated there can be adverse effects such as blood pressure going up, headache, fall risk, weakness, potential of being hospitalized . During an interview on 2/25/2024 at 3:30 p.m. with Director of Nursing (DON), the DON stated medications can be administered one hour before time due and one hour after. DON stated if medications are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 8 of 18 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 02/25/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete not given on time, it can affect the potency of the medication. DON stated by not following the physician's order there is more potential to get a reaction or adverse effects. DON stated this type of medication is supposed to release slowly through the day. DON stated you should not crush extended-release medication. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated, If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines. [NAME]-acting or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. Event ID: Facility ID: 055408 If continuation sheet Page 9 of 18 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 02/25/2024 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 observation, interview, and record review, the facility staff failed to ensure they were free of medication error rate of five (5) percent (%) or greater as evidenced by the identification of three (3) medication errors out of 29 opportunities for errors, to yield a facility medication error rate of 12 % for three of 11 sampled residents (Residents 29, 32, and 202). Residents Affected - Some 1. Resident 202 receive a crushed extended release (ER-designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) medication administration of metoprolol succinate (medication for high blood pressure) 2. During medication administration of metoprolol tartrate (medication to manage high blood pressure) for Resident 32 and metformin HCL (medication used to treat diabetes [abnormal sugar]) for Resident 29. Residents did not receive medication at the scheduled time and with food as ordered by the physician. These deficient practices had the potential to result in ineffectively managed hypertension and diabetes and may cause a harmful significant drop in the heart rate and blood pressure for Resident 32 and Resident 202, and hyperglycemia, hypoglycemia, and upset stomach for Resident 29. Findings: During a review of Resident 32's admission Record, dated 2/25/2024, the admission record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including hypertension (when the pressure in your blood vessels is too high), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). During a review of Resident 32's history and physical (H&P), dated 4/8/2023, the H&P indicated Resident 32 was able to make decisions for activities of daily living. During a review of Resident 32's order summary report (MD orders), dated 2/25/2024, the MD orders indicated there was an order starting from 2/10/2023 for metoprolol tartrate (medication for high blood pressure) 50mg with meals. During an observation on 2/24/2024 at 9:01 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 administered Metoprolol to Resident 32 without a meal or snacks. During an interview on 2/24/2024 at 3:02 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 32's medication metoprolol tartrate was to be given with food at 7:15 a.m. LVN 1 stated Resident 32 ate breakfast about 7:30 a.m. LVN 1 stated yes, the medication was given late, it was given around 9:50 a.m. During a review of Resident 29's admission Record, dated 2/25/2024, the admission record indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 10 of 18 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 02/25/2024 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 Resident 29 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart does not pump blood effectively), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining) and hypertension (when the pressure in your blood vessels is too high). During a review of Resident 29's history and physical (H&P), dated 6/1/2023, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's order summary report (MD orders), dated 2/25/2024, the MD orders indicated there was an order starting from 10/22/2022 for metformin HCl (medication used to treat diabetes [abnormal sugar]) tablet 500milligrams (mg - a unit of measure for mass) one time a day take with food. During a review of Resident 29's medication administration record (MAR), dated 2/1/2024-2/29/2024, the MAR indicated metformin HCL was to be given at 7:30 a.m. with food. During an observation on 2/24/2024 at 9:50 a.m. with LVN 1 at med cart 1, LVN 1 administered metformin to Resident 29 without a meal or snacks. During a subsequent interview on 2/24/2024 at 3:02 p.m. with LVN 1, LVN 1 stated Resident 29's medication Metformin HCL was to be given with food at 7:30 a.m. LVN stated Resident 29 ate breakfast about 7:30 a.m. LVN 1 stated yes, medication was given late, it was given around 9:00 a.m. LVN stated it is important to give medication on time to keep everything on balance. LVN 1 stated if giving without food it could potentially cause medication to be less effective, stomach issues. LVN 1 stated it is important to follow doctor orders. During a review of Resident 202's admission Record, dated 2/25/2024, the admission record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness characterized by extreme mood swings), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 202's history and physical (H&P), dated 2/24/2024, the H&P indicated Resident 202 had the capacity to understand and make decisions. The H&P indicated diagnoses including hypertension (when the pressure in your blood vessels is too high). During a review of Resident 202's order summary report (MD orders), dated 2/25/2024, the MD orders indicated there was an order starting from 2/10/2023 for metoprolol succinate (medication for high blood pressure) extended release (ER-designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) 24hour 50mg. During an observation on 2/24/2024 at 9:19 a.m. with LVN 1, LVN 1 crushed and administered metoprolol extended release to Resident 202. During an interview on 2/25/2024 at 9:52 a.m. with Registered Nurse (RN) 1, RN 1 stated that if medication is supposed to be given with meals and not it could potentially cause stomach issues. RN 1 stated an extended-release medication should not be crushed. RN 1 stated it is about the timing and the way it absorbs into the system. RN 1 stated if medication is crushed it could potentially be ineffective. RN 1 stated if medications are given late the condition the medication is used for can be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 11 of 18 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 02/25/2024 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 uncontrolled. RN 1 stated there can be adverse effects such as blood pressure going up, headache, fall risk, weakness, potential of being hospitalized . During an interview on 2/25/2024 at 3:30 p.m. with Director of Nursing (DON), the DON stated medications can be administered one hour before time due and one hour after. DON stated if medications are not given on time, it can affect the potency of the medication. DON stated by not following the physician's order there is more potential to get a reaction or adverse effects. DON stated this type of medication is supposed to release slowly through the day. DON stated you should not crush extended-release medication. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated, If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines. [NAME]-acting or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 12 of 18 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 02/25/2024 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 with open date (date food package was opened for use) label and food expiration date. Residents Affected - Many This practice put the facility residents at risk for infection by ingesting expired foods and can result in foodborne illnesses and symptoms such as nausea, vomiting, stomach cramps, and diarrhea. The expired foods are at risk for decreased flavor and taste. Findings: During a concurrent observation and interview with Kitchen Assistant (KA) 1, on 2/24/2024 at 6:58 a.m., of there was a seal plastic container with white powder thickener with a peeled label, on the kitchen counter. Surveyor was unable to observe any received-on, opened-on or expiration date. KA stated, there should be a label on the container. KA 1 stated, we need to know the date that container was opened. KA 1 stated, the kitchen staff need to know until when the product can be used. KA 1 stated, the label is very important, so residents do not eat any expired product. During a concurrent observation and interview with the Kitchen Supervisor (KS) on 2/24/2024 at 8:06 a.m., of the dry food storage, there was 1 open box with individual packages of ranch dressings without an opened-on date and no expiration date. The KS stated somebody must have forgot to put a label on the box. The KS stated, Yes it should have a label. The KS stated, it is important we know when a food package was opened and until when it can be used so we do not give expired products to residents. During an interview on 2/25/2024 at 9:18 a.m., with the KS, the KS stated, for the box with ranch dressing packages we follow the manufactures recommendations for expiration, so it is important to label with an opened-on date. The KA stated, feeding residents with expired products can causes diarrhea and abdominal pain. The KS stated, it is everybody's responsibility at the facility to take care of residents' health. During an interview on 2/25/2024 at 1:41 p.m., with the Director of Nursing (DON) the DON stated, the importance of labeling any received food product with open and expiration date is to prevent residents getting sick and getting an abdominal infection, or diarrhea due to consuming expired food. During a review of the facility's policies and procedures (P&P) titled Labeling and dating of foods, dated 2023 the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly open food items will need to be closed and label with an open date and used by date that follows the various storage guidelines within section-specifically the Dry Good Storage Guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 13 of 18 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 02/25/2024 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 0880 Provide and implement an infection prevention and control program. 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 review, the facility failed to follow their infection control policy for five out of 29 sampled residents (14, 32, 40, 153, and 202) by failing to: Residents Affected - Some A: Properly put on personal protective equipment (PPE, equipment used to prevent or minimize exposure to hazards) upon entering Resident 153's contact isolation room. B. Ensure oxygen tubing (plastic tubing applied to the nostrils that delivers life sustaining gases) was not on the ground for Resident 14. c. Disinfect the blood pressure cuff (tool used to measure blood pressure) after each use for Residents 32, 40, and 202. Findings: A. During a review of Resident 153's admission Record dated 2/27/2024, the admission Record indicated Resident 153 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI, an infection of the urinary system), extended spectrum beta lactamase (ESBL) resistance (bacterial infection resistant to a class of antibiotics), and multiple fractures (broken bones) of ribs. During a review of Resident 153's history and physical (H&P), dated 2/19/2024, the H&P indicated Resident 153 was able to understand and make decisions. During a review of Resident 153's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/24/2024, the MDS indicated Resident 153 was able to understand and be understood by others. The MDS indicated Resident 153 required set up assistance from staff for activities of daily living (ADLs) such as eating, required partial assistance from staff for oral hygiene and personal hygiene, and required substantial assistance from staff for toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear. During a review of Resident 153's order summary report (MD orders), dated 2/27/2024, the MD orders indicated starting from 2/17/2024, Resident 153 was on contact isolation (measures implemented to stop the spread of an infection) related to ESBL in urine. During a review of Resident 153's care plan titled infection, dated 2/17/2024, the care plan indicated Resident 153 had an alteration in immunologic (body's system to fight infections off) secondary to ESBL in urine and was on contact precautions and an intervention included to use PPE per facility protocol. During an observation on 2/25/2024 at 7:14 a.m., there was a contact isolation sign and PPE cart outside of Resident 153's door. Certified Nurse Assistant (CNA 1) was observed entering Resident 153's room to deliver a meal tray without donning PPE. During a subsequent interview on 2/25/2024 at 7:14 a.m. with CNA 1, CNA 1 stated she thought the last day of contact isolation was 2/14/2024 but she was not sure. CNA 1 stated she should have looked at the sign outside of Resident 153's door and put PPE on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 14 of 18 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 02/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/25/2024 at 9:11 a.m. with the Infection Preventionist Nurse (IPN) 1, IPN 1 stated even though Resident 153 had just completed antibiotics for ESBL, Resident 153 was on contact precautions for additional monitoring. IPN 1 stated staff entering Resident 153's room needed to wear PPE to provide care and if staff does not wear PPE into an isolation room, the staff can spread the infection. During an interview on 2/25/2024 at 2:42 p.m. with the Director of Nursing (DON), the DON stated Resident 153 was still placed under contact isolation and staff entering the room needed to wear PPE. The DON stated if the staff did not wear PPE, the staff could spread infection. During a review of Resident 14's admission Record, dated 2/25/2024, the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and last admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic kidney disease ([CKD], condition which the kidneys are damaged and cannot filter blood as well as they should), and type 2 diabetes mellitus (abnormal blood sugar). During a review of Resident 14's history and physical (H&P), dated 9/25/2023, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/29/2023, the MDS indicated Resident 14 was able to understand and be understood by others. The MDS indicated Resident 14 required set up assistance from staff for activities of daily living (ADLs) such as eating and oral hygiene and required supervision assistance from staff for personal hygiene, toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear. During a review of Resident 14's order summary report (MD orders), dated 2/25/2024, the MD orders indicated starting from 2/18/2024 was an order for oxygen at 3 Liters per minute as needed. During a concurrent observation and interview on 2/24/2024 at 2:51 p.m., with Licensed Vocational Nurse (LVN) 2 in Resident 14's room, the oxygen tubing was on the ground next to Resident 14's bed. LVN 2 stated the oxygen tubing is on the ground. LVN 2 stated there is potential for Resident 14 to get an infection by putting the contaminated oxygen tubing back in their nostrils. During an interview on 2/25/2024 at 3:30 p.m., with the Director of Nursing (DON), the DON stated the oxygen tubing should not be on the floor. The DON stated it is an infection control issue. During a review of Resident 32's admission Record, dated 2/25/2024, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including hypertension (when the pressure in your blood vessels is too high), schizoaffective disorder (a mental disorder with symptoms that cause a break with reality and mood disorder like depression), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). During a review of Resident 32's H&P, dated 4/8/2023, the H&P indicated Resident 32 was able to make decisions for activities of daily living. During a review of Resident 32's MD orders, dated 2/25/2024, the MD orders indicated there was an order starting from 2/10/2023 for metoprolol tartrate (medication for high blood pressure) 50milligrams (mg - a unit of measure for mass) with meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 15 of 18 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 02/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 40's admission Record, dated 2/25/2024, the admission record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease ([CKD], condition which the kidneys are damaged and cannot filter blood as well as they should) and hypertension (when the pressure in your blood vessels is too high). During a review of Resident 40's H&P, dated 7/6/2023, the H&P indicated Resident 40 does not have the capacity to understand and make decisions. During a review of Resident 202's admission Record, dated 2/25/2024, the admission record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness characterized by extreme mood swings), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 202's H&P, dated 2/24/2024, the H&P indicated Resident 202 had the capacity to understand and make decisions. The H&P indicated diagnoses including hypertension (when the pressure in your blood vessels is too high). During a review of Resident 202's MD orders, dated 2/25/2024, the MD orders indicated there was an order starting from 2/10/2023 for metoprolol succinate (medication for high blood pressure) extended release (ER-designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) 24hour 50mg. During an observation on 2/24/2024 at 9:01 a.m., with Licensed Vocational Nurse (LVN) 1 observing medication observation, the blood pressure cuff was not disinfected between use for three residents (Resident 32, 40, and 202). During an interview on 2/24/2024 at 3:02 p.m., with LVN 1, LVN 1 stated No, I did not disinfect the blood pressure cuff after using it. LVN 1 stated you need to disinfect the cuff after each use, and that was not done. LVN 1 stated it is important to disinfect for infection control, there could potentially be cross contamination of infection between residents. During a subsequent interview on 2/25/2024 at 3:30 p.m., with the Director of Nursing (DON), the DON stated you need to disinfect a blood pressure cuff after each use. The DON stated it is infection control, cross contaminate from resident to resident where you can spread infection. During a review of the facility's policy and procedure (P&P) titled Infection Control Transmission-Based Precautions, dated 2/2018, the P&P indicated contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the resident's room. During a review of the facility's policy and procedure (P&P) titled, Infection Control DME, (undated), the P&P indicated, It is the policy of the facility to properly and routinely sanitize durable medical equipment (DME); the following will be used to clean and disinfect these items between resident use: bleach wipes or germicidal wipes will be used for DME after each use. It is the responsibility of the nursing personnel to properly and routinely sanitize DME after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 16 of 18 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 02/25/2024 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 limit privacy for residents. Findings: During a review of the facility's Client Accommodations Analysis form, the form indicated the following resident bedrooms measured: room [ROOM NUMBER] (2 beds) 153.4 total, 76.8 square footage per resident room [ROOM NUMBER] (2 beds) 148.7 total, 74.4 square footage per resident room [ROOM NUMBER] (2 beds) 158.12 total, 79.0 square footage per resident room [ROOM NUMBER] (2 beds) 150.3 total, 75.2 square footage per resident room [ROOM NUMBER] (2 beds) 150.3 total, 75.2 square footage per resident room [ROOM NUMBER] (2 beds) 143.2 total, 71.6 square footage per resident room [ROOM NUMBER] (2 beds) 158.12 total, 79.0 square footage per resident room [ROOM NUMBER] (2 beds) 158.12 total, 79.0 square footage per resident room [ROOM NUMBER] (2 beds) 158.6 total, 79.3 square footage per resident room [ROOM NUMBER] (2 beds) 159.1 total, 79.6 square footage per resident room [ROOM NUMBER] (2 beds) 141.9 total, 70.8 square footage per resident The request indicated the rooms fall short of the minimum requirements, but the needs of the residents are fully accommodated. The request indicated the residents were able to move about freely, the toilets and closet space are easily accessible, and the facility is adequately equipped environmentally for comfort and privacy of residents. The request indicated there was adequate space for nursing care and residents can be quickly and safely evacuated in the event of an emergency. During the Resident Council meeting on 2/25/2024 at 11:06 a.m., there were no concerns brought up regarding room size. During an interview with the administrator (ADM) on 2/25/2024 at 3:15 p.m., the ADM stated some of the rooms are smaller than required but no residents have complained about the room size and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 17 of 18 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 02/25/2024 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 staff were able to provide adequate care to the residents. Level of Harm - Potential for minimal harm During observation from 2/24/2024 to 2/25/2024 of the facility and the residents' rooms, the residents in the facility did not have difficulty going in and out of their rooms. Each resident in the affected room had beds and side drawers and were satisfied with the room size. There was adequate room for the operation and use of wheelchairs and walkers. The nursing staff had full access to provide treatment, administer medications, and assist residents. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 18 of 18