F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of three sampled residents (Resident 1)
clothing was inventoried prior to being sent out to be laundered by an outside vendor.
This deficient practice resulted in the facility not knowing which clothing was being laundered by the outside
vendor and resulted in the loss of Resident 1 ' s clothing.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was
admitted on [DATE] with the diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same
side of the body) and hemiparesis (weakness or the inability to move on one side of the body).
During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident
assessment tool) dated 8/29/2024, the MDS indicated Resident 1 cognition was moderately impaired and
was dependent (helper does all the effort) on facility staff to complete activities of daily living (ADLs- routine
tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During an interview on 11/4/2024 at 1:11 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated
when the laundry is delivered to the facility, she will separate the clothes for each resident and there is no
inventory log of the clothing that is delivered.
During an interview on 11/7/2024 at 4:00 p.m. with Resident 1 ' s Responsible Party (RP), RP 1 stated
Resident 1 ' s clothing that was sent out by the facility to be laundered and was not found. The RP stated
the facility does not have a way to track the clothing that goes out for laundry.
During an interview on 11/8/2024 at 9:42 a.m. with the Director of Nursing (DON), the DON stated the
facility does not have an inventory list of what items are sent out to the laundry vendor and the facility
cannot ensure the items which are being sent out are being delivered back to the facility.
During a review of the facility ' s policy and procedure (P&P) titled Personal Property, dated 8/2022, the
P&P indicated resident belongings are treated with respect by facility staff, regardless of perceived value.
The P&P indicated resident ' s personal belongings and clothing are inventoried and documented upon
admission and updated as necessary.
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:
555805
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
555805
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bel Vista Healthcare Center
5001 East Anaheim Street
Long Beach, CA 90804
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of three sampled residents (Resident 1)
Interdisciplinary Team (IDT- a group of professional and direct care staff that have primary responsibility for
the development of a plan of care for the patient) Conference Notes accurately reflected the list of concerns
and topics discussed during the IDT meeting.
This deficient practice has the potential to result in a lack of communication and implementation of Resident
1 ' s plan of care.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was
admitted on [DATE] with the diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same
side of the body) and hemiparesis (weakness or the inability to move on one side of the body).
During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment too)
dated 8/29/2024, the MDS indicated Resident 1 cognition was moderately impaired and was dependent
(helper does all the effort) on facility staff to complete activities of daily living (ADLs- routine tasks/activities
such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 1 ' s Family Input/Concerns Interdisciplinary Care Plan Meeting Note dated
10/4/2024, the Family Input/Concerns Interdisciplinary Care Plan Meeting Note indicated topics discussed
including a list of concerns, nursing/medical conditions, dietary/nutrition plan, activities, toileting, and
Restorative Nurse Assistant (RNA).
During a review of Resident 1 ' s IDT Conference Note dated 10/4/2024, the IDT Conference Note indicated
the topics addressed during the IDT meeting included pain medication and consulting with the
pulmonologist. The IDT Conference Note did not reflect the family ' s concerns which were noted on the
Family Input/Concerns Interdisciplinary Care Plan Meeting Note dated 10/4/2024.
During an interview on 11/4/2024 at 11:13 a.m. with the Director of Nursing (DON), the DON stated she
receives the list of concerns from Resident 1 ' s RP via e-mail and those concerns are discussed in the IDT
meeting. The DON stated the concerns are not documented on Resident 1 ' s IDT Conference Note. The
DON stated the concerns should have been documented to accurately reflect the concerns that were
discussed in the IDT and the plan of care to resolve those concerns.
During a review of the facility ' s policy and procedure (P&P) titled Care-Planning Interdisciplinary Team,
dated 3/2022, the P&P indicated the resident ' s family and/or the resident ' s legal representative/guardian
or surrogate are encouraged to participate in the development of and revisions of the resident ' s care plan.
During a review of the facility ' s P&P titled Care Plans, Comprehensive Person Centered, dated 3/2022,
the P&P indicated assessments of residents are ongoing and care plans are revised as information about
the residents and the residents ' condition change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555805
If continuation sheet
Page 2 of 2
