Health inspection·January 28, 2026

F 0557 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge process was followed for one of five sampled residents (Resident 1). * The discharge section of the Resident's Clothing and Possessions form for Resident 1 was not completed. This failure had the potential to affect the ability of the resident or resident's responsible party to be informed of their belongings.Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/19/22, showed it is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility. Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The Policy Explanation and Compliance Guidelines showed the licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Closed medical record review for Resident 1 was initiated on 1/23/26. Resident 1 was admitted to the facility on [DATE], and discharged on 1/5/26. Review of Resident 1's Resident's Clothing and Possessions form dated 12/12/25, showed two sections on the form. The bottom section showed On Admission with various types of items the resident brought with them on admission. The top section of the form showed On Discharge. The On Discharge section showed a slash across the form with the words discharge AMA. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. On 1/28/26 at 1047 hours, an interview and concurrent closed medical document review for Resident 1 was conducted with CNA 5. CNA 5 verified Resident 1's Resident's Clothing and Possessions form showed the On Discharge section of the form was incomplete. CNA 5 stated Resident 1's belongings should have been counted and sorted by the licensed nurse or a CNA and placed in the bag with Resident 1's name. CNA 5 stated the licensed nurse or CNA should have given the resident's belongings to the social services. On 1/28/26 at 1318 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with RN 2. RN 2 verified Resident 1's Resident's Clothing and Possessions form was incomplete. RN 2 stated the licensed nurse or the CNA team lead should have filled the form to make sure there were no items missing. On 1/28/26 at 1545 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON acknowledged the above findings. The DON stated Resident 1's Resident's Clothing and Possessions form should have been filled out when the staff packed everything. The DON stated whoever packed the belongings should have specified the items on the form so the facility would have an accurate account of Resident 1's belongings. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055622 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 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)