Health inspection·September 27, 2024

F 0656 dressing. Level of Harm - Minimal harm or potential for actual harm During an concurrent interview and record review on 9/27/2024 at 3:34 p.m. with the Director of Nursing (DON), Residents 1, 3, and 4's Care Plans were reviewed. The DON stated there were no Covid-19 care plans in place for the residents. The DON stated Care Plans had nursing care interventions that were needed to implement for a problem. The DON also stated care plans were important because that was how the facility could determine if an intervention was effective or not. Residents Affected - Some During a review of facility's undated Policy and Procedure (P&P) titled, Policy and Procedure on Care Plan, the P&P indicated, the facility shall ensure the development of a comprehensive care plan for each resident to meet his/her medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment. The P&P indicated Care Plans should be reviewed whenever necessary, either as a result of a significant change in the resident's status and condition, or of discontinued plan of care based on new information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056218 If continuation sheet Page 2 of 5 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 056218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for Covid-19 (A highly contagious respiratory disease caused by the SARS-CoV-2 virus) by failing to: Residents Affected - Some a. Ensure staff donned (put on) personal protective equipment ([PPE], equipment worn to prevent spread of infections or diseases such as a gown, face shield [cover/protection] and gloves) prior to entering a Covid-19 positive room (room [ROOM NUMBER]). b. Ensure staff doffed (removed) PPE prior to leaving Covid-19 positive Room (room [ROOM NUMBER]). c. Conduct close contact testing of exposed staff after one resident (Resident 1) tested positive for Covid-19 on 9/5/2024. d. Adequately screen facility visitors prior entering facility during a Covid-19 outbreak. e. Report the facility ' s Covid-19 outbreak to the California Department of Public Health (CDPH) on 9/8/2024. These failures had the potential to result in the spread of Covid-19 and placed residents, staff, and the community at risk of contracting Covid-19, hospitalization, and death. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and Hypertension ([HTN] high blood pressure). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federal mandated resident assessment tool) dated 7/23/2024, the MDS indicated Resident 1 was usually able to understand and be understood by others. The MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as toileting hygiene and lower body dressing. During a review of Resident 1 ' s Change of Condition (COC), dated 9/5/2024, the COC indicated Resident 1 tested positive for Covid-19 on 9/5/2024. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Urinary Tract Infection ([UTI] an infection in the bladder/urinary tract). During a review of Resident 3 ' s MDS dated [DATE], the MDs indicated Resident 3 had the capacity to understand and be understood by others. The MDS indicated Resident 3 required substantial/maximal assistance from staff for ADLs such as showering/bathing and supervision/touching assistance (staff provides verbal cues and/or touching assistance as resident completes activity) for lower body dressing and putting/taking off footwear. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056218 If continuation sheet Page 3 of 5 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 056218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 3 ' s COC dated 9/7/2024, the COC indicated Resident 3 tested positive for Covid-19 on 9/7/2024. a. During a concurrent observation and interview on 9/26/2024 at 8:03 a.m., Licensed Vocational Nurse (LVN) 1 was observed entering a Covid-19 Positive Room (room [ROOM NUMBER]) to get a blood pressure cuff without donning PPE. LVN 1 stated she should have donned all PPE equipment prior to entering the room to promote infection control. LVN 1 stated, not donning PPE places staff at risk of getting an infection and spreading Covid-19. b. During a concurrent observation and interview on 9/26/2024 at 8:06 a.m., Maintenance Supervisor (MS) was observed leaving a Covid positive room (room [ROOM NUMBER]), with PPE on including gloves, face shield, and gown. MS stated he should have removed his PPE prior to exiting the Covid positive room because the PPE he was wearing were contaminated (unclean, soiled). During an interview on 9/26/2024 at 9:34 a.m. with the Director of Nursing (DON), the DON stated staff should always wear PPE prior to entering a Covid positive room to provide protection for the staff and the patient. The DON also stated staff were to remove PPE prior to exiting a Covid positive room to not have contaminated PPE in the hallway. During a record review of facility ' s Policy and Procedure (P&P) titled, Coronavirus Disease (Covid-19) – Infection Prevention and Control Measures, dated 07/2020, the P&P indicated, while in the building, personnel are required to strictly adhere to established infection control policies, including the appropriate use of PPE. The P&P also indicated, for a resident with known or suspected Covid-19 staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. c. During an interview on 9/26/2024 at 12:28 p.m. with the DON, the DON stated, the facility tested Resident 1 ' s roommate after Resident 1 tested positive on 9/5/2024 and no staff were tested for Covid-19. The DON stated, he was not sure who else to test. The DON stated response testing (testing performed to individuals who might have been exposed and possibly infected after identifying one infected case) had not been initiated until 9/8/2024. During an interview on 9/26/2024 at 3:28 p.m. with the Department of Public Health Nurse (PHN), PHN stated, the facility should have tested staff right away because they were likely exposed to Covid-19. The PHN stated, failing to test staff who had close contact to the residents with Covid-19 could spread the virus. During an interview on 9/27/2024 at 3:34 p.m. with the DON, the DON stated, if close contacts of Covid-19 positive residents or staff were not tested, it increased the risk of not being able to detect additional Covid-19 infected residents or staff to help prevent the spread of the virus. During a review of facility ' s undated P&P titled, Coronavirus Disease (Covid-19) Updated Policy on Surveillance, Testing, Reporting, and Staffing Guidance, dated 10/7/2022, the P&P indicated, testing will continue to be performed for resident and staff with higher-risk exposure to Covid-19 (i.e., as part of response testing). The P&P also indicated, all staff and residents who have had close contacts (within 6 feet for cumulative total of 15 minutes over 24 hours), regardless of vaccination status, will be tested promptly. d. During a concurrent record review and interview on 9/26/2024 at 4:03 p.m. with Certified Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056218 If continuation sheet Page 4 of 5 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 056218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assistant (CNA) 5, the Visitor Screening Log, dated 9/26/2024, was reviewed. CNA 5 stated she was assigned to screen visitors that day. CNA 5 stated part of the facility ' s Covid-19 screening process included visitors to complete required questions on the visitor log including temperature, any signs, and symptoms of Covid-19, and whether the visitor had any contact with anyone who was diagnosed or suspected with Covid-19. CNA 5 stated, the Visitor Screening Log was not completed that day for some visitors and some sections were left blank and unanswered. During a concurrent record review and interview on 9/27/2024 at 3:34 p.m. with the DON, the Visitor Screening Log dated 9/26/2024 was reviewed. The DON stated visitors should be screened for Covid-19 prior to entering the facility. The DON stated, the facility staff would offer a Covid-19 test prior to entering the facility if the visitor answered yes, to any of the questions on the Covid-19 Visitor Screening Log. The DON also stated, if the questions were left blank, the facility would not know if a visitor had symptoms or was sick with Covid-19. During a review of the facility ' s P&P titled, Coronavirus Disease (Covid-19)-Infection Prevention and Control Measures dated 7/2020, the P&P indicated anyone entering the facility is screened and triaged for signs and symptoms of and exposure to others with Covid-19 infection including fever, cough, shortness of breath. The P&P indicated anyone with signs and symptoms of illness or has been advised to self-quarantine (stay away from others) due to exposure is not allowed to enter the facility. e. During interviews on 9/26/2024 at 9:05 a.m. and 9/26/2024 at 10:11 a.m. with the DON, the DON stated, the facility ' s Covid-19 outbreak started on 9/8/2024. During a concurrent record review and interview on 9/27/2024 at 3:34 p.m. with the DON, All Facilities Letter ([AFL] letter informing the facility of changes in requirements in healthcare, enforcement or general information affecting the health facility) 23-08 dated 1/19/2023 was reviewed. The DON stated, the facility should have reported to Covid-19 outbreak to the CDPH licensing district office (DO), however, was not done. The DON stated, if an outbreak was not reported, the facility would not get assistance to control the spread of the outbreak. During a review of the facility ' s P&P titled, Coronavirus Disease (Covid-19)- Infection Prevention and Control Measures dated 7/2020, the P&P indicated the facility follows recommended standard to prevent the transmission of Covid-19 within the facility. The P&P indicated the health department is notified of any resident with suspected or confirmed Covid-19 During a record review of facility ' s P&P titled, Coronavirus Disease (Covid-19) updated Policy on Surveillance, Testing, Reporting, and Staffing Guidance dated, 10/7/2022, the P&P indicated, the health department is notified of any resident with suspected or confirmed Covid-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056218 If continuation sheet Page 5 of 5