Health inspection·January 23, 2026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Restorative Nurse Assistant (RNA 1) accurately documented for one of three sampled residents (Resident 1), indicating Resident 1 received RNA services when there was no order and when those services were not provided. This deficient practice resulted in RNA 1 documenting Resident 1 was provided passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises, to her bilateral lower ([BL] both legs) and bilateral upper extremities ([BLE] both upper arms), a splint (a rigid material or apparatus used to support in impaired joint) was applied to his right knee, and pressure relief ankle foot orthosis boot ([PRAFO] a specialized orthopedic boot designed to position the foot and ankle correctly, relieve pressure on the heel, and prevent complications such as pressure ulcers and contractures [permanent and painful tightening of the muscles that restricts movement]), when those services were not provided.This deficient practice had the potential to result in inaccurate care for the resident. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), contracture of the right and left ankle and right and left hand, and abnormal posture.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2025, the MDS indicated Resident 1 was dependent (resident does none of the effort to complete the activity) on facility staff with toileting, upper and lower body dressing, personal hygiene and eating. During a review of Resident 1's Interdisciplinary (IDT) Notes dated 1/7/2026, the IDT notes indicates the team identified pressure and friction from the orthopedic devices (tools used to prevent sores and tightening and shortening of the muscles) may have contributed to the superficial abrasions and skin discoloration of the bilateral lower extremities. These devices were placed on hold and orders were discontinued once the abrasions were identified to prevent Resident 1 from having further skin breakdown. During a record review of Resident 1's Documentation Survey Report ([DSR] document indicating when RNA services are provided by staff) RNA 1 documented the following services were provided to Resident 1:1. On 1/12/2026 at 8 a.m., RNA 1 documented she provided PROM to Resident 1's right and left BUE and BLE, applied Resident 1's right knee extension splint, and applied Resident 1's PRFAO boots.2. On 1/13/2026 at 11:45 a.m., RNA 1 documented she provided PROM to Resident 1's right and left BUE and BLE, applied Resident 1's right knee extension splint, and applied Resident 1's PRAFO boots.During a review of Resident 1's Order Summary Report (Physician's Orders) dated 1/12/2026 and 1/13/2026, the Physician's Order indicated there were no orders indicating Resident 1 was to receive RNA services.During a review of Resident 1's Physician's Orders dated 1/19/2026, an order was placed for RNA to apply right knee extension split and PRAFO four to six hours a day as tolerated, RNA program for Resident 1 to receive PROM to right and Page 1 of 2 056042 056042 01/23/2026 Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left lower extremities five days a week, and PROM to right and left upper extremities five times a week or as tolerated. During a concurrent interview and record review on 1/21/2026 at 12:43 p.m., with Registered Nurse 1 (RN 1), Resident 1's medical records were reviewed. RN 1 stated on 1/6/2026 Resident 1 was discharged to a General Acute Care Hospital (GACH). RN 1 stated upon discharge, the Physician's Orders indicated facility staff to hold the application of Resident 1's right knee extension splint, PROM to BLE and PRAFO boots due to swelling and abrasions on BLE. RN 1 stated when Resident 1 returned to the facility, the previous orders were not resumed. During a concurrent interview and record review on 1/21/2026 at 2 p.m., with RNA 1, Resident 1's DSR dated 1/12/2026 and 1/13/2026 was reviewed. RNA 1 stated on 1/12/26 and 1/13/2026 she documented that she applied Resident 1's right knee extension splint and PRAFO and provided PROM to Resident 1's BLE. RNA 1 stated she did not perform the PROM, apply right knee splint or the bilateral PRAFO's because there were no physician's orders at that time. RNA 1 acknowledged that her documentation was entered by mistake and confirmed that the error should not have occurred. During a concurrent interview and record review on 1/22/2026 at 3:30 p.m., with the Director of Nursing (DON), Resident 1's medical records were reviewed. The DON stated on 1/7/2026 there was an IDT meeting and the IDT decided to hold Resident 1's order for PRAFO boots and right knee extension splint due to Resident 1 having bilateral foot swelling and superficial abrasions. The DON stated Resident 1's orders for PRAFO boots, right knee splint and PROM to bilateral upper and lower extremities were resumed on 1/19/2026 and that RNA 1 should not have documented that she provided RNA services on 1/12/2026 and 1/13/2026 when there was no order and if the services were not provided. The DON stated documentation needs to be accurate so that staff know what is being done for the residents.During a review of the facility's policy and procedure (P&P) titled, Documentation, revised 1/12/2012, the P&P indicated resident progress in the Restorative Nursing Program is documented accurately and timely. The P&P indicated physicians orders are to be obtained prior to the resident's participation to the Restorative Nursing Program for Ambulation Range of Motion Restorative program. 056042 Page 2 of 2