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 (continued on next page) 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: 056042 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 056042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805 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)