Health inspection·May 13, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the status of one of three sample residents (Resident 1)'s alleged abuse allegation was assessed and monitored. Residents Affected - Few These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being by not receiving the needed and necessary services timely. Findings: During a review of Resident 1's admission record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified sequelae (long term effect) of cerebral infarction (stroke: blockage that disrupts blood flow to the brain leading to brain), slurred speech, and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 4/22/2025, the H&P indicated Resident 1 is not able to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/18/2025, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 1 is dependent on toileting hygiene, lower body (waist below) dressing, required maximal assistance (provide more than half the effort) for toilet transfer, chair/bed-to-chair transfer, bathing, upper body (waist above), and required supervision for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 has an impairment on one side of the lower (hips/legs) extremities and utilized a wheelchair. During a review of the Change in Condition (COC) Evaluation dated 5/9/2025, from a report reported by Social Service Director (SSD), Nurse Practitioner 1 (NP 1) reported during her visit with Resident 1, Resident 1 verbalized her breast and vagina was fondled, inappropriately touched by a male staff. During a review of the progress notes for the 72-hour (hr.) charting, the progress notes indicated there was a 72-hr charting dated 5/10/2025 at 10:05 a.m., 5/10/2025 at 10:29 a.m., and 5/13/2025 at 4:04 a.m. During a concurrent interview and record review on 5/13/2025 at 2:09 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated a COC is something that is out of the ordinary, and once a COC is initiated, the doctor and family are notified, a care plan is created, document on the progress notes, Page 1 of 2 555805 555805 05/13/2025 Bel Vista Healthcare Center 5001 East Anaheim Street Long Beach, CA 90804

F 0684 Level of Harm - Minimal harm or potential for actual harm and the resident with have a 72-hr monitoring. LVN 2 stated if there is a COC, there should be 72-hr. monitoring. LVN 2 stated the COC on 5/9/2025 indicated Resident 1 verbalized an alleged abuse by a staff and is not sure what Resident 1 should be on monitoring for. LVN 2 stated the 72-hr monitoring is documented in the progress note for every shift and Resident 1 should have been on monitoring until 5/12/2025. LVN 2 stated they monitor the residents to see if there's any development regarding the COC. Residents Affected - Few During an interview on 5/13/2025 at 2:56p.m. with Director of Nursing Covering Consultant (DONCC), DONCC stated when there is an alleged abuse allegation, ensure the resident is safe and secure, assess the resident, notify the doctor, family, start the investigation, and report to the Administrator (ADM) since they are responsible for contacting the local police, Ombudsman, and California Department of Public Health (CDPH). DONCC stated the residents will be monitored for 72-hr, the SSD will visit the residents to ensure they feel safe and there are no psychosocial issues. DONCC stated the residents will be monitored for 72-hr every shift when there is a COC, and if there's no 72-hr monitoring, how would they be able to identify the COC in a resident if there's no monitoring. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised date February 2021, the P&P indicated the nurse will record in the resident's medical information relative to changes in the resident's medical/mental condition or status. 555805 Page 2 of 2