Health inspection·March 5, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure a baseline care plan for one of three sampled residents (Resident 1). Resident 1 did not have a baseline care plan that identified that Resident 1 refused and Resident 1 ' s family member (FM) refused to attend the Integrated Discharge Disciplinary Team (IDT the Residents health care team made up of various specialties). This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to her needs. Findings: During a review of Resident 1 ' s admission Record the admission Record indicated the facility admitted Resident 1 o the facility on 12/31/2022 and readmitted her on 1/25/2024 with diagnoses of essential (primary) hypertension (high blood pressure, pulmonary fibrosis, unspecified (a disease where there is scarring of the lungs making it hard to breath) and rheumatoid arthritis , unspecified (a chronic progressive disease-causing inflammation in the joints). During a review of Resident 1 ' s history and physical (H&P) report dated 12/30/2022, the H&P indicated resident 1 had the ability to understand and make decisions. During a review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 1/30/2024, the MDS indicated Resident 1 is dependent (helper does all of the effort. Resident puts forth none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with showering, upper and lower body dressing. During a record review of Resident 1 ' s progress notes a late entry entered and dated 1/30/2024 indicated Resident 1 and Resident 1 ' s daughter had declined to attend IDT meetings. During a review of Residents 1 ' s medical record, the medical record indicated the last IDT meeting was on 10/11/2023. During an interview on 3/5/2024 at 1:16 p.m., with the Social Worker (SW), the SW stated facility staff had an ITD meeting with Resident 1 and Resident 1 ' s daughter on 10/11/ 2023. The SW stated this is when Resident 1 and her daughter stated they did not want to attend future IDT meetings. The SW also stated that she I did not explain the risks and benefits of IDT meetings to the Resident 1 or her daughter. The SW stated when the resident and/or the resident ' s representative do not attend (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: 056104 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 056104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Villa Health Care Center 9028 Rose Street 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)