Health inspection·October 22, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some plan.During a concurrent interview and record review on 10/17/2025 at 3:05 p.m. with the Infection Preventionist Nurse (IPN), the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/2017, was reviewed. The Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings indicated, Control measures and limits should be established for each control point. You will need to monitor to ensure your control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value. Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring. Water heaters should be maintained at appropriate temperatures. Disinfectant (a chemical liquid that destroys bacteria) and other chemical levels should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (slime) should be cleaned. The IPN stated, the facility did not have the water management policy and followed CDC's water management program guidelines. The IPN stated, the facility should have implemented all control measures and control limit according to CDC's guidelines since the facility followed as the policy and procedures. The IPN stated, the MS should have monitored and documented the water quality, water temperature, and disinfectant level to reduce risk of Legionella growth. During a review of the facility's Policy and Procedures(P&P) titled, Policy for Legionnaire's Disease, revised 6/2017, the P&P indicated, Process to Develop a Water Management Program: The facility will determine risk areas by completing the Building Water System Process Flowchart and implement controls and indicate where these controls are located by completing the Control Area Monitoring Flowchart.During a review of the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/2017, the Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings indicated, Documentation: written program should include at least the following: Water system description, including general summary, uses of water, aerosol-generating devices (e.g., hot tubs, decorative fountains, cooling towers), and process flow diagrams. Control measures, including points in the system where critical limits can be monitored and where control can be applied.B. During an interview on 10/17/2025, at 11:46 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, Resident 1 had respiratory symptoms such as coughing and shortness of breath on 9/29/2025. RNS 1 stated, Resident 1 was transferred to General Acute Care Hospital (GACH) due to change of condition on 9/30/2025 and re-admitted to the facility on [DATE]. RNS 1 stated, she did not receive information regarding the positive result of Legionella UAT from GACH for Resident 1, and staff did not know about it until the Public Health Nurse notified IPN on 10/15/2025.During a concurrent interview and record review on 10/17/2025, at 2:24 p.m., with RNS 1, Resident 1's GACH Progress Note, dated 10/4/2025, the GACH Progress Note indicated, Resident 1 was diagnosed with Legionella pneumonia and was on Levaquin (a medication to treat a variety of bacterial infections). RNS 1 stated, it was RN Supervisors' responsibility to review all the pre-admission documents upon admission and the admission RNS should have reviewed Resident 1's GACH medical record thoroughly. RNS 1 stated, if the staff did not review the admission documentation thoroughly, critical information like this could delay the resident's treatment and care.During an interview on 10/17/2025, at 2:30 p.m., with the IPN, IPN stated, she would have reported the unusual occurrence (any condition or event which has jeopardized or could jeopardize the health, safety, security or well-being of any patient, employee or any other person while in the facility) within 24 hours if she knew about Resident 1 having legionella infection. The IPN stated, GACH did not inform it, but she realized that it was indicated on Resident 1's medical record. The IPN stated, this would place all the residents at the facility at risk of being exposed to infectious disease unknowingly and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 2 of 4 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 10/22/2025 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 delay the care. The IPN stated, the facility was notified by Public Health Nurse Liaison (a registered nurse who acts as a crucial communication bridge between public health agencies and other healthcare settings to improve disease reporting, surveillance, and public health initiatives) on 10/15/2025.During a concurrent interview and record review on 10/17/2025, at 2:42 p.m., with the Director of Nursing (DON), Resident 1's History and Physical (H&P), dated 10/8/2025 was reviewed. The H&P indicated, admission to the facility for continued rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) and medical management following hospitalization for acute hypoxic respiratory failure (the lungs cannot adequately oxygenate the blood) secondary to Legionella pneumonia. The DON stated, the staff, including herself, failed to review Resident 1's medical record thoroughly. The DON stated, this would delay the proper care and treatment. The DON stated, if she knew about Resident 1's legionella infection, she would have reported it to CDPH right away to investigate the case. The DON stated, missing critical information regarding certain infections could result in spreading infection and exposing vulnerable residents to danger.During a review of Resident 1's GACH Legionella UAT , dated 10/2/2025, the GACH Legionella UAT positive result was reported on 10/2/2025 at 10:35 a.m During a review of Resident1's Discharge Summary EMR, dated 10/6/2025, the Discharge Summary EMR indicated, Resident 1 had legionella pneumonia and received Levaquin.During a review of the facility's Policy and Procedure (P&P) titled, Unusual Occurrence Reporting, revised 8/2018, the P&P indicated, Policy: It is the facility policy that, in accordance with federal and/or state regulations, unusual occurrences or other reportable events which affect the health, safety or welfare of residents, employees or visitors be reported. Procedure: Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.During a review of the facility's Policy and Procedure (P&P) titled, Policy for Legionnaire's Disease, revised 6/2017, the P&P indicated, Policy: Policy: It is the policy of the facility to have a plan for the prevention of Legionnaire's disease, recognize the signs and symptoms of the disease, test as appropriate with a physician's order and report confirmed cases to the local and state health department. Legionella is a reportable disease and the local county and state health departments should be notified of confirmed disease.C. During a concurrent interview and record review on 10/17/2025, at 3:05 p.m., with the IPN, the facility's Policy and Procedure(P&P) titled, Policy for Legionnaire's Disease, revised 6/2017 was reviewed. The P&P indicated, The facility will develop a Water Management Program which will be reviewed annually. The IPN stated, last revised policy was on 6/2017, and it was supposed to be reviewed and updated annually. The IPN stated, she could not provide evidence that indicated it was reviewed and updated annually. The IPN stated, P&P should be reviewed and updated for any changes to accommodate new health orders (a written directive issued by a government's public health authority to control or prevent risks to public health).During a concurrent interview and record review on 10/17/2025, at 3:30 p.m., with the Administrator (ADM), the facility's Quality Assurance and Performance Improvement (QAPI Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) binder, dated from 2/2025 to 10/2025 was reviewed. There was no documentation regarding review, revise, and update the infection control and water management policies annually. The ADM stated, he believed QAPI team discussed the policy and procedure during the QAPI meeting, but he could not provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055408 If continuation sheet Page 3 of 4 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 10/22/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete evidence or documentation. The ADM stated, review and update the P&P was important to let the staff know any recent changes on practice and guidance.During a review of the facility's Policy and Procedure(P&P) titled, Infection Control Program, revised 7/2022, the P&P indicated, Educational Component: The Quality Improvement Program will include a structured system with stated guideline and regular, active participants; standard procedures for inspection and action.Infection Control Plan: The Infection Control Committee will establish policies and procedures for the investigation, control and prevention of transmission of disease and infections within the facility.Establish and implement guidelines and procedures. Assist each department in establishing policies and procedures for infection control and provide ongoing evaluation of current measures and policies within each department Event ID: Facility ID: 055408 If continuation sheet Page 4 of 4