Health inspection·January 16, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some himself.During a review of Resident 1's Actual Fall Care Plan dated 10/13/2025, the Care Plan indicated Resident 1 had a fall due to poor balance. The Care Plan goal indicated Resident 1 will resume usual activities without further incident and interventions including educating Resident 1 to call for assistance when needed.During a review of Resident 1's SBAR, dated 10/28/2025 and timed at 4:10 a.m., the SBAR indicated Resident 1 was found sitting on the floor mat (a cushioned pad placed on the floor next to a resident's bed or chair to reduce the severity of injuries if the resident falls) and Resident 1 stated he fell from the left side of bed while turning.During an interview on 1/15/1026 at 10:29 a.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 was able to walk but with assistance and always needed someone to help him. CNA 1 stated Resident 1 was confused sometimes, used a cane and a wheelchair, had a right arm splint (a strip of right material used for supporting and immobilizing a body part) and he had never used the call light. CNA 1 stated that Resident 1 never used the call light when he needed something she would make rounds at least once an hour if she could see if he needed anything.During an interview on 1/15/2026 at 11:16 a.m., Registered Nurse (RN) 1 stated Resident 1 was a high fall risk and would get up unassisted all the time even if they encouraged him to use the call light. RN 1 stated sometimes he was confused but sometimes he preferred to be independent. RN 1 stated when someone falls, they initiate an investigation and will interview the residents and witnesses to determine what happened and prevent future falls.b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), dementia (a progressive state of decline in mental), altered mental status (a sudden change in brain function, causing confusion, disorientation, poor attention, unusual behavior, or unresponsiveness), and unspecified fall.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort, by either lifting, holding, or supporting trunk or limbs) with ambulating up to 10 feet.During a review of Resident 2's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 2 was assessed as a high fall risk. During a review of Resident 2's At Risk for Falls Care Plan dated 11/13/2025, the Care Plan indicated Resident 2 was at risk for falls related to his dementia, right eye cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), and history of falls. The Care Plan goal indicated to minimize the risk of injury for Resident 2 and interventions including to be sure the Resident 2's call light was within reach and for staff to encourage Resident 2 to use it to call for assistance as needed.During a review of Resident 2's Physical Therapy (PT) Treatment Encounter Note, dated 11/21/2025, the PT Treatment Encounter Note indicated Resident 2 needed Contract Guard Assistance ([CGA] a caregiver or therapist keeps one or two hands on a person during movement, like walking or transferring, to provide balance support and prevent falls, but doesn't do the work for them).During a review of Resident 2's Nursing Note, dated 11/22/2025, and timed at 10:45 a.m., the Nursing Note indicated on 11/22/2025 at 10:15 a.m., Resident 2 had an unwitnessed fall and was found sitting on the floor in his room. The Nursing Note indicated Resident 2 stated he fell on his butt when attempting to sit down.During a review of Resident 2's Actual Fall Care Plan dated 11/22/2025, the Care Plan indicated Resident 2 had an actual fall, and the Care Plan goal was for Resident 2 to resume usual activities without further incident. The Care Plan interventions included determining and addressing the causative factors of the fall.During an interview on 1/15/2026 at 11:04 a.m., Certified Nursing Assistant (CNA) 2 stated Resident 1 liked to be independent, would ambulate in his room, and would go to the bathroom by himself. CNA 1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056104 If continuation sheet Page 2 of 3 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 01/16/2026 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete due to a past fall he had they were instructed to keep an eye on him, which although it was not specified, she would check on him at least once an hour. CNA 2 stated Resident 2 was able to ambulate on his own and required assistance to the restroom only. During an interview on 1/15/2026 at 12:13 p.m., the Director of Rehabilitation (DOR) stated Resident 2 was not allowed to walk alone and needed someone within arm's reach when ambulating because he was at a high fall risk due to his cognition, multiple history of falls, and required moderate assistance from staff when ambulating. The DOR stated that after a resident falls, the rehabilitation (rehab) department will evaluate the residents within three days of the fall to determine if there was an injury and to determine the cause of the fall for safety reasons. The DOR stated during the evaluation, the rehab department will interview the resident and the nurses to determine what happened and discuss it with the team in order to minimize the risk of future falls. The DOR stated rehab did not evaluate Resident 1 after this second fall on 10/28/2025, and because of that they had not discussed this with the IDT team. The DOR stated rehab services, and an IDT meeting should have occurred after Resident 1's fall on 10/28/2025, to prevent any potential future falls.During an interview on 1/16/2026 at 12:37 p.m., the Director of Nursing (DON) stated Resident 1 had cognitive impairment and was not sure if he was assessed for his ability to understand and follow instructions on using the call light. The DON stated Resident 2 also had cognitive impairment and she was not sure about his ability to learn to use the call light. The DON stated that because Resident 1 and Resident 2 had not used the call light when needing help, the intervention was ineffective, and other interventions should have been in place like more frequent rounds and monitoring at least once every 2 hours. The DON stated that after every fall the facility will investigate the fall and the team will have a meeting and write their investigation in the conclusion in the Post-Event IDT note, however they did not do a Post-Event IDT note after Resident 1's second fall on 10/28/2025 or Resident 2's first fall on 11/22/2025. The DON stated the reason why they investigate the fall is to find the cause and update the care plan to prevent more falls, and that not investigating the fall 10/28/2025 and 11/22/2025 could have led to another fall for Resident 1 and Resident 2. The DON stated they communicate fall risk residents during rounds and report, and that all staff should be aware of the high risk for fall residents and what interventions should be done. The DON stated she was not sure why some of the staff believed it was appropriate for Resident 2 to ambulate without assistance, but this could cause him to fall again if staff are unaware that he needs assistance for all ambulating activities. The DON stated they did not investigate the fall for Resident 2 because he was hospitalized the next day and at the time they anticipated his return.During a review of facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning, dated 1/2022, the P&P indicated the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated interventions are measurable; able to be evaluated or quantified.During a review of facility's P&P titled Fall Management System, dated 1/2022, the P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. The P&P indicated the care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. The P&P indicated review of the fall incident will include investigation to determine probably causal factors and will be reviewed by the IDT. Event ID: Facility ID: 056104 If continuation sheet Page 3 of 3