Health inspection·July 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, The facility failed to respect residents' right to receive visitors without limitation. This failure has the potential to disrupt resident's psychosocial well-being, cause emotional distress, and negatively affect the quality of care provided. During an interview on 7/8/2025 at 7:25 a.m. with Receptionist 1, Receptionist 1 stated that they recommended two visitors per resident to prevent the room being crowded. During a concurrent observation and Interview on 7/8/2025 at 12:38 p.m. with Receptionist 2 at the facility entrance, observed one signage on the receptionist's desks stating, only two people allowed in residents room per visit. Receptionist 2 stated that the facility limits visitors to two people per visit and the facility remained the sign on the receptionist's desk for several years. During an interview on 7/9/2025 at 1:18 p.m. with Family Member (FM) 1, FM 1 stated that there are two visitor limit guidelines at this policy, but the facility does not follow their own policy, he saw a bunch of people celebrating one resident's birthday. During a concurrent observation and interview on 7/9/2025 at 1:25 p.m., observed that the facility did not post the ‘two people allowed' sign on the receptionist's desk on the observation date. Receptionist 2 stated that, for some reason, the visitor limit sign was not present on that date. During an interview on 7/9/2025 at 2:28 p.m., Resident 1 stated that he heard from his family that up to two people can visit him at the same time. During an interview on 7/9/2025 at 2:48 p.m. with the Social Service Director (SSD), the SSD stated that residents have the right to unlimited visitors, the signage on the reception desk was incorrect and Inconsistent posting of the sign could affect resident's psychosocial well-being. The SSD stated if rooms are too small for visitors, the facility can provide alternative spaces like the patio or activity room. During the interview on 7/10/2025 at 1:10 p.m. with the Administrator (ADM), the ADM stated that they can have unlimited visitors, and this is the residents' right. The ADM stated If a room becomes overcrowded or issues arise, alternatives like activity room or patio can be provided instead of limiting visitor numbers. The ADM stated that failing to honor it could upset residents, lead to complaints, affect quality of care, or cause emotional distress and depression. During the review of the facility's policy and procedure(P&P), titled Residents' rights, no dated, the P&P indicated that This facility shall encourage visiting by family members and friends of all residents residing in the facility, In addition, cheerful and comfortable visiting areas are provided in which the residents may welcome and converse freely with their visitors. Page 1 of 6 056405 056405 07/10/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow facility's own restraint policy for one of three sample residents (Resident 2) by not:a. trying alternatives prior to use of abdominal binderb. completing the informed restraint consent.c. monitoring every 30 minutes while on use.d. developing a care plan for abdominal binder (a supportive garment that wraps around the abdomen and provides compression and support) restraint (limiting or controlling something, whether it's a person's actions, emotions, or physical movement). These deficient practices have the potential to place the residents at risk for unnecessary prolonged use of restraints and can lead to a decline in physical functioning, and residents not being treated with respect and dignity with the use of restraints.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breath), dysphagia (difficulty swallowing), type two diabetes mellitus (a condition where the body does not use insulin properly, and our blood sugar levels become too high) and dysphagia (difficulty swallowing) with gastrostomy (a surgically created opening into the stomach, often for the purpose of inserting a feeding tube). During a review of Resident 2's History and Physical (H&P), dated 5/11/2025, the H&P indicated, Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 2's cognitive (functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort) with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/ taking off footwear, and personal hygiene. During a review of Resident 2's Order Summary Report, as of 7/8/2025, the Order Summary Report indicated there was an order, created on 5/9/2025, support and safety device, may apply abdominal binder to minimize the risk of resident pulling out life sustaining gastrostomy tube (a flexible tube inserted through the abdominal wall into the stomach) and prevent potential injury, and may release during activities of daily living. During a review of Resident 2's Restraint-Physical initial evaluation, dated 5/10/2025 at 00:22 a.m., the restraint evaluation indicated that no alternatives attempted to reduce risk of harm to Resident 2 were attempted prior to the application of the restraint. During a review of Resident 2's Informed Consent, dated 5/10/2025, the informed consent indicated that the proposed treatment was applying abdominal binder. The informed consent form did not have a physician's signature. During a review of Resident 2's medical records, there was no care plan addressing Resident 2's abdominal binder restraint. During an observation on 7/7/2025 at 4:40 p.m., in Resident 2's room, Resident 2 was wearing an abdomen binder. During a concurrent interview and record review on 7/8/2025 at 10:51a.m., with Licensed Vocational Nurse (LVN) 2, the informed consent, dated 5/10/2025was reviewed. LVN 2 stated that Resident 1 had the abdominal binder as a restraint and staff should obtain the restraint informed consent. The informed consent regarding the abdominal restraint on 5/10/2025 was incomplete due to the absence of the physician's signature and date. LVN 2 stated that Staff should monitor Resident 2 while the restraint binder in use to ensure that it is fastened properly, not too constrictive or tight, and that the skin is not affected. LVN 2 stated that there was no documented monitoring while the abdominal restraint was in use. During a concurrent interview and record review on 7/8/2025 at 2:51p.m., with 20Registered Nurse (RN)1, Resident 2's Restraint-Physical initial evaluation, dated 5/10/25 at 12:22 a.m., was reviewed. RN 1 stated Staff did not attempt alternative interventions prior to the initial use of abdominal binder on 5/10/2025 at 00:00, to reduce or avoid the use Residents Affected - Few 056405 Page 2 of 6 056405 07/10/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of restraint. RN 1 stated Resident 2 had COPD which causes difficulty breathing, and staff did not monitor or assess Resident 2 every 30 minutes while the abdominal binder restraint was in use. RN 1 stated that staff should monitor and assess comfort, tolerance, breathing difficulties, and proper application, and no such record was found. RN 1 stated that there was no specific care plan regarding the abdominal binder restraint. RN 1 stated that failure to follow the restraint policy could lead to resident neglect, unrecognized distress, or actions against residents' will. During an interview on 7/10/2025 at 11:34 a.m., with the Assistant of Director of Nursing (ADON), the ADON stated that staff had to obtain the informed consent prior to apply restraint, should first try less restricting alternatives, such as 1:1 companionship, medication review, or engaging in activities. The ADON stated use of restraints should be the last resource. The ADON stated that the personalized Care plan should be developed and reflect Resident 2's need for abdominal binder restraint. ADON stated that staff should observe the resident at least every 30 minutes while the restraint in use, as Resident 2's multiple comorbidities could cause discomfort and dignity issues if not properly monitored. During a review of the facility's policy and procedure (P&P) titled, Use of restraint, dated 2017, the P&P indicated that, Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. The ongoing re-evaluation for the need for restraints will be documented. Orders for emergency restraints shall be signed by the physician within forty-eight 48 hours. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms), but the underlying problems that may be causing the symptom (s), care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. Documentation regarding the use of restraints shall include the length of effectiveness of the restraint time; and observation, range of motion and repositioning flow sheets. 056405 Page 3 of 6 056405 07/10/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to restraints and alarms was accurately documented for one of two sample residents (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breath), and dysphagia (difficulty swallowing) with gastrostomy (a surgically created opening into the stomach, often for the purpose of inserting a feeding tube). During a review of Resident 2's MDS, dated [DATE], The MDS indicated Resident 2 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/ taking off footwear, and personal hygiene. The MDS, Section P, indicated Resident 2 did not have restraints (limiting or controlling something, weather it's a person's actions, emotions, or physical movement) During a review of Resident 2's Restraint-Physical initial evaluation, dated 5/10/2025, the restraint evaluation indicated that staff initiated an abdominal binder restraint on Resident 2 on 5/10/2025 at 00:00. During a concurrent interview and record review on 7/8/2025 at 2:22 p.m., with Registered Nurse (RN) 2, RN 2 stated that Resident 2 wore the abdominal binder, she did not mark it as a restraint on the MDS section P because she did not consider it a restraint.RN 2 stated that accurate entries on the MDS were important because they reflect the care provided to residents; if not assessed accurately, the facility cannot identify the correct status of the patient. During a concurrent interview and record review on 7/8/2025 at 2:51p.m., with Registered Nurse (RN)1, RN 1 stated that abdominal binder used for Resident 2 was considered a restraint, and the MDS coordinator should mark it as a restraint on the MDS. During an interview on 7/10/2025 at 11:34 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that Resident 2's abdominal binder was a restraint, Accurate assessment is important and should be accurately documented in the system, as MDS serves as the basis of care planning, billing purposes, and ensuring that the patient receives the appropriate quality of care of the patient's need. During a review of the facility's policy and procedure (P&P) titled, certifying accuracy of the resident assessment, undated, indicated, any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. During a review of the facility's P&P titled, Resident assessment, undated, indicated that comprehensive assessment includes completion of the Minimum Data Set (MDS); All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. Residents Affected - Few 056405 Page 4 of 6 056405 07/10/2025 Cerritos Vista Healthcare Center 17836 Woodruff Avenue Bellflower, CA 90706

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 Facility failed to assess comprehensively one of three sampled residents (Resident 2) by not assessing and monitoring Resident 2's toenail detachment status after it began bleeding for five days.This failure had the potential to delay necessary medical intervention, leading to complications such as infection, pain, or further injury.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breath), dysphagia (difficulty swallowing), type two diabetes mellitus (a condition where the body does not use insulin properly, and our blood sugar levels become too high), the admission record also indicated that long term use of anticoagulants (blood thinners). During a review of Resident 2's History and Physical (H&P), dated 5/11/2025, indicated, Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/15/2025, indicated Resident 2's cognitive (functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making were moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/ taking off footwear, and personal hygiene. During a review of Resident 2's Order Summary Report, as of 7/8/2025, the Order Summary Report indicated there was an order, dated 5/9/2025, to administer one table of apixaban (a blood thinner) oral tablet 2.5 milligram (unit does) through gastrostomy tube( a tube inserted thought the abdominal wall into the stomach) two times a day for atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and rapidly). During a review of Resident 2's COC (change of condition-any significant alteration in a patient's physical, mental, emotional, or functional status)/interact assessment form (SBAR-situation, background, assessment and recommendation), dated 5/20/2025, the COC assessment form indicated that Resident 2's daughter reported RN 1 that her toe was bleeding, RN 1 noted dried blood underneath the fifth toe (pinky toe) of left foot. During an observation on 7/8/2025 at 10:10 a.m. in Resident 2's room, observed no toenail on Resident's left 5th toe. During a concurrent interview and record review on 7/8/2025 at 2:51 p.m. with Registered Nurse (RN) 1, COC assessment form (SBAR), dated 5/20/2025 was reviewed, RN 1 stated that Resident 2's left toe started to bleed on the day, RN 1 assessed the resident and MD made aware with order to have treatment nurse assess and evaluate. RN 1 stated that Resident 2's toenail was already detached and gone completely upon RN 1's return to work 6 days later. RN 1 stated that the treatment nurse, Licensed Vocational Nurse (LVN)1 assessed Resident 2 after the toenail was fully removed. RN 1 stated this was a delayed intervention and not consistent with quality care. During a concurrent interview and record review on 7/8/2025 at 4:43 p.m. with the Director of Nursing (DON), Resident 2's COC assessment form and nursing progress notes, dated from 5/20/25 to 5/25/2025 were reviewed. The DON stated that there was no documentation regarding the status of toenail's detachment, after the initial COC assessment. During an interview on 7/9/2025 at 1:32 p.m. with Licensed Vocational nurse (LVN) 1, LVN 1 stated, her role included monitoring and assessing any skin issues. LVN 1 stated that Resident 2 had diabetes and was at risk of bleeding. When Resident 2 experienced bleeding on her toe, assessing and monitoring were important. LVN 1 stated that there was no follow-up treatment documentation regarding the bleeding on her toe. During an interview on 7/10/2025 at 11:34 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that when the patient is diabetes, was on a blood thinner, and began bleeding on the toe area, it could indicate a diabetic foot complication. Staff should assess, monitor and document the source of bleeding, circulation, and signs of infection for at least 72 hours or Residents Affected - Few 056405 Page 5 of 6 056405 07/10/2025 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 longer to allow early intervention. The ADON stated that there was no documentation regarding circulation, infection signs, or, bleeding source, and there was no treatment nurse's documentation. The progress of the toenail coming off was not assessed for several days. And 6 days later, it detached and finally fell off after then seen late by podiatrist after the toenail had gone. The ADON stated that proper documentation and timely communication are essential. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 1/24/2017 indicated that documentation of change in condition shall be performed by the licensed Nurse accordingly. Documenting for at least 72hours or longer if condition change warrants. During a review of the facility's P&P titled, Charting and Documentation, revised 07/2017, indicated that Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The P&P indicated that Documentation of procedures and treatments will include care-specific details, including: the assessment data and/or any unusual findings obtained during the procedure/treatment. During a review of the facility's P&P titled, change in a Resident's Condition or Status, revised 2/2021, indicated that If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. During a review of the facility's P&P titled, Change of Condition, revised 1/24/2027, indicated that documentation of change in condition shall be performed by the licensed nurse accordingly: documenting for at least 72 hours or longer if condition change warrants. 056405 Page 6 of 6