Health inspection·June 16, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to complete and document a comprehensive assessment (a complete head to toe physical evaluation), blood pressure (measurement of amount of force your blood uses to get through your arteries), heat rate, temperature, and blood glucose (amount of sugar in the body) measurements after one of one sampled resident (Resident 1) vomited. Residents Affected - Few These deficient practice had the potential to result in delay of care and services which can result in poor health outcomes. Findings: During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 on 5/18/2025 with a diagnosis including pneumonia (an infection/inflammation in the lungs), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), attention to gastrostomy status (g- tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dependence of supplemental oxygen (treatment that provides you with extra oxygen to breathe), and heart failure (heart can't pump enough oxygen-rich blood to meet your body's needs). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 5/19/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the task) with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's COC/Interact Assessment Form (SBAR) , dated 5/20/2025 at 10:12 a.m., the SBAR (Situation Background Assessment Request - a communication tool used by healthcare workers when there is a change of condition among the residents) indicated Resident 1 vomited at 7:30 a.m. During an interview on 6/11/2025 at 1:51 p.m. with the Registered Nurse (RN) 1, Resident 1's medical records were reviewed. RN 1 stated according to the medical records Resident 1 vomited on 5/20/2025 at around 7:30 a.m. and RN 2 did not complete a comprehensive change of condition assessment. RN 1 stated RN 2 did not check and document Resident 1's blood glucose level, blood pressure, heart rate and temperature after Resident 1 vomited. During an interview on 6/13/2025 at 2:33 p.m., with the Director of Nursing (DON), the DON stated after a resident has a change of condition, the staff should do a head-to-toe assessment and check vital signs (measurements of basic functions of the body) to ascertain if there's a problem and to catch problems early and to initiate prompt interventions as needed. Page 1 of 5 056405 056405 06/16/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or status , revised 2/2021, the P&P indicated the nurse will make a detailed observation and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR Communication Form. A significant change of condition is a major decline or improvement in resident's status that impacts more than one area of the resident's health status and ultimately is based on the judgement of the clinical staff. 056405 Page 2 of 5 056405 06/16/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some Based on interview and record review, the facility failed to turn and reposition two of three sampled residents (Resident 5 and 6) with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) every two hours and/or as needed. These deficient practices placed Resident 5 and 6 at risk for poor wound healing. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and end stage renal disease (irreversible kidney failure). During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 5/2/2025, the MDS indicated Resident 5's cognitive skills (ability to think and reason) for daily decision-making were severely impaired. The MDS indicated Resident 5 required set up assistance with eating, oral hygiene, personal hygiene; Resident 5 was dependent (helper does all the effort. Resident does none of the effort to complete activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, showering; and Resident 5 required partial assistance (helper does less than half the effort helper lifts support or holds trunk or limbs but provides less than half the effort) when rolling left and right (ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 5 was at risk for developing pressure injuries. The MDS indicated Resident 5 was NOT on a turning and repositioning program. During a review of Resident 5's admission Reassessment, dated 5/26/2025 7:43 a.m., the Reassessment indicated Resident 5 had the following pressure ulcers: a. In the sacrum (tailbone area), Resident 5 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough [dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds] and/or eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off] in the wound bed. b. In the right gluteus (buttocks) and in the left heel, Resident 5 had a deep tissue injury (DTI – Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] with diagnoses including acute kidney failure, diabetes, muscle weakness, and Stage IV pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (tail bone). 056405 Page 3 of 5 056405 06/16/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision-making were intact. The MDS indicated Resident 6 required partial assistance with personal hygiene and oral hygiene; and Resident 6 was dependent with toileting hygiene, showering, and rolling left and right. The MDS indicated Resident 6 was at risk for developing pressure injuries. The MDS indicated Resident 6 had a Stage IV pressure ulcer upon admission to the facility. The MDS indicated Resident 6 was NOT on a turning and repositioning program. During an interview and record review on 6/12/2025 at 12:23 p.m., with Licensed Vocational Nurse (LVN)1, Resident 5's Documentation Survey Report for 5/2025 and 6/2025, and Resident 6's Documentation Survey Report for 4/20/2025 and 5/2025 were reviewed and the reports indicated the task of Turn and Reposition every 2 hours or as needed were left blank in some shifts. LVN 1 stated if the shifts were left blank it meant that the staff did not perform the task. LVN 1 stated Residents 5 and 6 were not turned and repositioned every 2 hours or as needed every shift. LVN 1 stated staff was supposed to turn and reposition residents every 2 hours and as needed to relieve pressure from the pressure ulcers to help the pressure ulcers heal. During an interview on 6/12/2025 at 1:19 p.m., with the Director of Nursing (DON), the DON stated it was important to turn the residents with pressure ulcers at least every 2 hours and as needed. The DON stated if it was not documented it was not done. During a review of Pressure Injury Prevention Points Portable Document Format (PDF) published by the National Pressure Injury Prevention Advisory Panel, copyright 2020, the PDF indicated the following pressure injury prevention points: 1. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning and repositioning. 2. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 3. Continue to reposition an individual when placed on any support surface. 4. Reposition weak or immobile individuals in chairs hourly (www.npiap.com) During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure injuries revised 4/2020, the P&P indicated to prevent the development of skin breakdown/pressure injuries to reposition residents. The P&P indicated to choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 056405 Page 4 of 5 056405 06/16/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure medication administration was documented in the Medication administration Record for one of two sampled residents (Resident 1). Residents Affected - Few These deficient practice resulted in an incomplete depiction of care and services provided to Resident 1 which can result in poor health outcome. Findings: During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 on 5/18/2025 with a diagnosis including pneumonia (an infection/inflammation in the lungs), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), attention to gastrostomy status (g- tube -a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dependence of supplemental oxygen (treatment that provides you with extra oxygen to breathe), and heart failure (heart can't pump enough oxygen-rich blood to meet your body's needs). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 5/19/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the task) with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Order Summary report, active orders as of 5/18/2025, the orders indicated, starting 5/18/2025, Ondansetron (medication for nausea and vomiting) 4 milligrams via G-tube every eight hours as needed for nausea and vomiting. During a review of Resident 1's COC/Interact Assessment Form (SBAR) , dated 5/20/2025 at 10:12 a.m., the SBAR (Situation Background Assessment Request - a communication tool used by healthcare workers when there is a change of condition among the residents) indicated Resident 1 vomited at 7:30 a.m. During an interview and record review on 6/12/2025 at 1:32 p.m. with Registered Nurse (RN) 2, Resident 1's Medication Administration Record (MAR) for May 2025 was reviewed. The MAR indicated that Ondansetron was not administered in May 2025. RN 2 stated that he administered Ondansetron on 5/20/2025 at 7:45 a.m. and mentioned that medication administration should always be documented. During an interview on 6/13/2025 at 2:33 p.m., with the Director of Nursing (DON), the DON stated medication administered need to be documented in the MAR as indicated in the policy. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated medications administration are documented by licensed personnel. 056405 Page 5 of 5