Health inspection·May 18, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 2's progress notes dated 5/18/2025, the progress note dated 1/31/2025 at 11:57 a.m. indicated Dermatologist 1 (DERM 1) was called for a dermatology consult and treatment as indicated for right hand lesions. DERM 1 requested the face sheet and to take a photograph of lesions on Resident 2's right hand. During a review of Resident 2's physician order sheet from DERM 1 dated 3/26/2025, the physician order sheet indicated to fax a signed consent form to schedule a biopsy to rule out basal cell (most common type of skin cancer)/ squamous cell carcinoma (type of skin cancer that makes up the outermost layer of the skin). During a review of Resident 2's skin biopsy consent form, there are no dates and signature indicated on the consent form. During a concurrent observation and interview on 5/17/2025 at 10:43 a.m. with Resident 2, Resident 2 stated she has had this skin issue for about six months. Resident 2 stated the facility is aware, and she had not received any medication, and the facility has not done anything for her. It was observed Resident 2 had two raised bumps on her right hand. During a concurrent interview and record review on 5/18/2025 at 11:34 a.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the order for Resident 2 indicated there was an order for a dermatology consult on 1/31/2025. RNS 1 stated when there is an order for a dermatology consult, they will schedule and make an appointment with dermatology. RNS 1 stated depending on the insurance the Case Manager (CM) or the Social Service Director (SSD) will get prior authorization for the referral and fax the documents to the clinic. RNS 1 stated per order, Resident 2 should have a dermatology consultation appointment. RNS 1 stated the progress note on 1/31/2025, indicated DERM 1 asked for Resident 2's face sheet to be faxed over. RNS 1 stated the DERM 1 physician order sheet indicated the informed consent to be faxed, but the informed consent was not signed. RNS 1 stated there are no notations in March, April, and May 2025 regarding the dermatology consultation and indicated it is not known if a signed consent form was faxed to the dermatology clinic. RNS 1 stated the informed consent should have been signed and sent out at that time. RNS 1 stated the nurses usually follow up with the documents and indicated this was communicated from the nurses to DERM 1 and DERM 1 requested the face sheet. RNS 1 stated it is known what happened afterwards and usually follow up within 72 hours (hr.). RNS 1 stated if the resident does not receive the intended consultation, their condition can get worse and affect the health of the resident. During an interview on 5/18/2025 at 6:57p.m. with the Administrator (ADM), the ADM stated the previous Director of Nursing (DON) was in charge of all ancillary services (services that support, or supplement primary care provided by doctors and nurses) and was aware that Resident 2 had an order summary by DERM 1 in March 2025 and was not followed up. The ADM stated at that time, it was DON's responsibility and indicated that the residents not receiving the intended consultation is a huge issue as it can potentially lead to a more serious issue, and this could have been easily preventable had they made an appointment, and they did not. During an interview on 5/18/2025 at 8:38p.m. with the DON, the DON stated it was important for residents to get consultations if needed, and if there is an order, the resident should get the consultation. 2.During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 2 of 23 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 05/18/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some condition where the body has trouble controlling blood sugar) with hyperglycemia (elevated sugar in the blood), type 2 diabetes mellitus with diabetic neuropathy arthropathy (nerve damage and joint disease), hypertension (high blood pressure) and acquired absence of right leg above knee. During a review of Resident 28's history and physical (H&P), dated 5/15/2025 the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS), a resident assessment tool dated 3 /31 /2025, the MDS indicated Resident 28 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity) with eating, and personal hygiene, substantial / maximal assistance (helper lifts and holds trunk or limbs, provides more than half the effort ) with lower body dressing, shower/bathe self and putting on /taking off footwear. During a record review of Resident 28's Treatment Administration Record (TAR) dated 5/16/2025 , the TAR indicated right AKA (surgical incision) cleanse with normal saline (sterile water), apply xeroform (wound dressing), ABD pad (a highly absorbent medical dressing used to manage heavily draining wounds)and wrap with kerlix (used to secure and protect wounds , injuries or surgical sites ) every day shift x 30 days . Another order with a start date of 5/15/2025 indicated to monitor surgical incision daily every day shift. And last order dated 5/15/2025 indicated to monitor dressing integrity daily every day shift. During an observation and interview on 5/18/2025 at 11:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 28 was in bed with his right AKA without a dressing . LVN 3 stated she was aware resident had no dressing . LVN 3 states it was important to keep Resident 28's surgical wound covered with dressing to prevent infection. During an interview on 5/18/2025 at 12:30 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she was not aware Resident 28 had no dressing to his right AKA. RN 1 stated it was important to keep Resident 28's right AKA surgical site completely covered to prevent infection, and it to follow the doctor's order. During an interview on 5/18/2025 at 8:00 p.m. with the Director of Nursing (DON), the DON stated we must follow doctors order and keep the wound covered and provide a dressing to prevent infection. During a review of the facility's policies and Procedures (P&P), titled Resident Rights, revised date February 2021, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; communication with and access to people and services, both inside and outside the facility. During a review of the facility's P&P, titled Dignity, revised date February 2021, the P&P indicated each resident shall be cared for in a matter that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. During a review of the facility's policy and procedure (P&P) titled Residents Rights indicates federal and state laws guarantees certain basic rights to all residents of this facility these rights (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 3 of 23 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 05/18/2025 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 0684 include the residents right to : Equal access to quality care, regardless of source of payment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 4 of 23 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 05/18/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of ten sampled residents (Resident 21 and 28) had their admission/readmission assessments completed by Registered Nurses (RNs) This deficient practice had the potential for delay in care and services, due to missed or inaccurate identification of problems. a. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified fracture (break in a bone) of unspecified lumbar vertebra (one of the bones that make up the spinal column in the lower back), spinal stenosis (space inside the backbone is too small putting pressure on the spinal cord), and obstructive (urine flow is blocked) and reflux uropathy (occurs when urine flows backward into the bladder often as a result of obstruction). During a review of Resident 21's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21 Minimum Data Set [MDS] a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 21'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 21 is dependent on chair/bed-to-chair transfer and toileting hygiene, required maximal assistance (provide more than half the effort) for bathing, dressing upper (above waist) and lower (waist below) body, required supervision on personal hygiene and oral hygiene, and required set up for eating. The MDS indicated Resident 21 utilizes a wheelchair and has bilateral (both sides) impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 21's Change of Condition (COC) dated 5/13/2025 at 4:26p.m., the COC indicatred Resident 21 was sent to the hospital for further evaluation for a left elbow skin tear and right forearm skin tear. During an interview on 5/18/2025 at 5:41p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated upon admission, they get the paperwork, introduce the resident, review the resident, do skin assessments with the Certified Nursing Assistant (CNA), assess for smoking, check if they are a fall risk, and do the Braden Scale (tool used to assess a patient's risk for developing damaged skin and tissue). LVN 2 stated they do the head-to-toe assessment and indicated the RN does not do the admission assessments. LVN 2 stated the Licensed Vocational Nurses are the ones that do the skin assessment, and it was primarily their responsibility to do the admission assessments not the Registered Nurses. LVN 2 stated if there is a serious incident such as a fall or bleed, they will notify the RN so they can assess the resident. LVN 2 stated if they do not have an RN, they will notify the physician. During a concurrent interview and record review on 5/18/2025 at 5:49 p.m. with LVN 2, LVN 2 stated Resident 21 went and came back from the hospital and usually an LVN will not do a full readmission assessment if the resident comes back from the hospital in the same day. LVN 2 stated the progress note indicated on 5/14/2025 at 12:55a.m., there is documentation that the resident returned from the hospital. LVN 2 stated the skin and pain assessment needs to be completed. LVN 2 stated there was no reassessment done by an LVN or an RN when Resident 21 returned back from the hospital and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 5 of 23 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 05/18/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm supposed to do an assessment. LVN 2 stated an assessment is supposed to be done as Resident 21 has been on a gurney in the emergency room and you want to assess to ensure theres no new issues, and ensure the resident is not in pain. LVN 2 stated if there are no readmission assessments done, the resident may have skin breakdown, so it is important to cover all the basis as they are there to take care of the residents and make sure they are okay. Residents Affected - Some b. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's H&P, dated 5/15/2025, the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28 MDS dated [DATE], the MDS indicated Resident 2's cognitive skills were severely impaired. The MDS indicated Resident 28 is dependent on chair/bed-to-chair transfer, toilet transfer, toileting hygiene, required maximal assistance for lower body dressing, bathing, required moderate assistance (provide less than half the effort) for oral hygiene and upper body dressing, and required supervision for eating and personal hygiene. The MDS indicated Resident 28 utilizes a wheelchair and has bilateral impairments on the lower extremities. During a review of Resident 28's Admission/readmission Evaluation/assessment dated [DATE], the admission/readmission evaluation indicated this assessment document was completed by Licensed Vocational Nurse 3 (LVN 3). During a concurrent interview and record review on 5/18/2025 at 3:54 p.m., with Infection Preventionist Nurse (IPN), the IPN stated the LVN's have been doing the admission assessments and Registered Nurse Supervisor 1 (RNS 1) helps and does the care plans. the IPN stated RNS 1 also does the admission assessments, but most of the time, the LVNs do the admission assessments. The IPN stated that when the resident is admitted , the admission assessments have to be documented right away. The IPN stated that when a resident goes to the hospital and comes right back to the facility, they have to do an admission/readmission evaluation assessment right away as the resident might have bruising, there may be new medication orders, and does not want the facility to be blamed. IPN stated they also have to do the skin check and is done by the LVNs. During an interview on 5/18/2025 at 4:01p.m., with RNS 1, RNS 1 stated for admission, transfer, and discharge assessments, the LVN does it and she helps. During an interview on 5/18/2025 at 8:31p.m. with Director of Nursing (DON), the DON stated the Registered Nurses (RN) does not usually do the admissions and indicated any licensed nurse can do the head-to-toe assessment. The DON stated if the LVN completes the head-to-toe assessment, the RN should verify the assessment themselves. The DON stated RN completes a comprehensive assessment of the resident because they oversee the plan of care, treatments, and ensure issues are not missed. During a review of the facility's policies and Procedures (P&P), titled Job Description: Registered Nurse (RN), dated 1/2025, the P&P indicated participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident as necessary. Ensure that all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 6 of 23 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 05/18/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some personnel involved in providing care to the resident are aware of the resident's care plan. Review nurses' notes to determine if the care plan is being followed. Review resident's medical and nursing treatments to ensure that they are provided in accordance with the resident's care plan and wishes. During a review of the facility's P&P, titled Job Description: Director of Nursing revised 1/2025, the P&P indicated the DON is a registered nurse who oversees and supervises the care of all the residents. Essential Duties: Overall management of the entire nursing department and staffing levels. Responsible for ensuring resident safety and that all residents are treated with utmost respect. Liaison between the facility, physicians and family members. Work closely with all other departments to ensure excellent overall resident care. I know During a review of the facility's P&P, titled admission Assessment and Follow Up: Role of the Nurse revised September 2012, the P&P indicated the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including MDS. 7. Conduct an admission assessment (history and physical), including a. A summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission. b. Relevant medical, social, and family history FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 7 of 23 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 05/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, and administering drugs and biologicals per physician orders to meet the needs of each resident for two out of five sampled residents (Resident 1 and 21) by: 1.Failing to follow up with the Medication Regimen Review (MRR: comprehensive evaluation of resident's medication performed by a pharmacist to promote positive outcomes and minimize adverse consequences) recommendations for Resident 1. 2.Failing to communicate new medication order to the pharmacy for Resident 1. 3.Failing to follow doctors orders and remove Lidoderm External Patch five (5) percent (%) (Lidocaine: medication that numbs specific area of the body by blocking pain signals to the brain) for Resident 21. These deficient practices had the potential for Resident 1 to not receive medication to address pain appropriately and increased the risk for adverse reactions for Resident 21 by leaving the Lidocaine patch longer than 12 hours (hrs). 1. 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 cerebral infarction (stroke - loss of blood flow to a part of the brain) and osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 1 had moderate cognition (ability to learn, reason, remember, understand, and make decisions) impairment with the ability to recall information, required supervision when eating, required maximal assistance (helper does more than half of the effort) for dressing, and was dependent (helper does all of the effort) for showering and bathing. During a review of Resident 1's Physician Order Summary, the Order Summary indicated Resident 1 had an order for: a.Hydrocodone-acetaminophen (strong pain medication) tablet 5-325 milligrams (MG-unit of measurement) give one tablet by mouth every six hours as needed for severe pain (6-10 pain level) with start date 4/3/2025 and an end date 4/20/2025. b.Hydrocodone-acetaminophen tablet 5-325 MG give one tablet by mouth every six hours as needed for moderate pain (4-6 pain level) with start date 4/20/2025. During an observation on 5/18/2025 at 8:30 a.m., in Resident 1's room, Resident 1 reported a pain level of 7 out of 10. Licensed vocational nurse (LVN) 4 administered one tablet of hydrocodone-acetaminophen tablet 5-325 MG to Resident 1. During a concurrent interview and record review on 5/18/2025 at 10:10 a.m. with Licensed vocational nurse (LVN) 4, Resident 1's order summary, medication blister pack (type of tamper evident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 8 of 23 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 05/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some packaging that separates medication by dose), and reconciliation count sheet were reviewed. LVN 4 stated Resident 1's order summary indicated hydrocodone-acetaminophen tablet 5-325 MG is to be given for moderate pain (4-6). LVN 4 stated the blister pack and the reconciliation count sheet indicated hydrocodone-acetaminophen 5-325 MG for severe pain (6-10). During a concurrent interview and record review on 5/18/2025 at 1:11 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's MRR for hydrocodone-acetaminophen 5-325 MG dated 4/29/2025 was reviewed. The MRR indicated pharmacist (PHARM) 1 recommended to the facility to ensure that the order on the pain assessment flow sheet (also known as the MAR-Medication administration record) matches with the reconciliation or count sheet (Paper documentation for narcotic and controlled substance medications). RNS 1 stated she reviewed Resident 1's MRR and left a message with the MD on 5/17/2025. RNS 1 stated they should have reviewed the pain assessments on the MAR and compared it to the reconciliation sheet . During an interview on 5/18/2025 at 2:52 p.m., with pharmacist (PHARM) 2, PHARM 2 stated when a medication order is changed or updated, the facility has to print and fax the new order to the pharmacy. PHARM 2 stated the pharmacy did not receive an updated order for Resident 1 which indicated hydrocodone-acetaminophen 5-325 MG for moderate pain (4-6). During an interview on 5/18/2025 at 7:27 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated if a medication order's parameters were changed, it should have been faxed to the pharmacy. LVN 2 stated it is the LVN's responsibility to ensure the medication blister pack has the correctly ordered dose and parameters. During an interview 5/18/2025 at 11:29 a.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated MRR recommendations should be followed up with or acted upon within 5 days. RNS 2 stated the pain medication order should have been clarified with the physician and addressed. RNS 2 stated Resident 1 was at risk for pain not being managed adequately. During an interview on 5/18/2025 at 8:08 p.m., with the Director of Nursing (DON), the DON stated it is important for medications to be administered within the ordered pain level parameters. The DON stated if there is a discrepancy, the nurse should have clarified the order with the physician. The DON stated if the blister pack does not match the order, it can potentially cause a medication error. The DON stated Resident 1 could be at risk for being under or over medicated. During a review of the facility's policies and Procedures (P&P), titled Medication Regimen Reviews, revised February 2025, the P&P indicated the MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities . irregularities may include incorrect medications, administration times, or dosage forms; or other medication errors, including those related to documentation. The P&P indicated upon receiving the MRR report from the pharmacist, the attending physician review and responds to the report .if the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or the administrator. 3. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified fracture (break in a bone) of unspecified lumbar vertebra (one of the bones that make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 9 of 23 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 05/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some up the spinal column in the lower back), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and spinal stenosis (space inside the backbone is too small putting pressure on the spinal cord). During a review of Resident 21's H&P, dated 4/20/2025, the H&P indicated Resident 21 has the capacity to understand and make decisions. During a review of Resident 21 MDS, dated [DATE], the MDS indicated Resident 21's cognitive skills were mildly impaired. The MDS indicated Resident 21 was dependent on chair/bed-to-chair transfer and toileting hygiene, required maximal assistance (provide more than half the effort) for bathing, dressing upper (above waist) and lower (waist below) body, required supervision on personal hygiene and oral hygiene, and required set up for eating. The MDS indicated Resident 21 utilizes a wheelchair and has bilateral (both sides) impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 21's Order Summary Report (physician orders) dated 5/18/2025, the order summary indicated Lidoderm External Patch five (5) percent (%) (Lidocaine: medication that numbs specific area of the body by blocking pain signals to the brain): apply to low back topically (applied to the skin) in the morning for low back pain for 14 days. Apply in the morning and remove at bedtime for 14 days. The Lidoderm order was placed on 5/15/2025 and started on 5/16/2025. During a review of the Medication Administration Record (MAR: detailed record of medication administered to residents) dated 5/1/2025 - 5/31/2025, the MAR indicated Lidoderm External Patch 5% scheduled at 9:00a.m. was administered on 5/16/2025 and 5/17/2025. There is no indication that the Lidoderm External Patch 5% was removed at bedtime. During a review of the location of the administration report dated 5/1/2025 thru 5/31/2025, the administration report indicated the Lidoderm External Patch 5% was administered at the following times: 5/16/2025 administration time 10:21 a.m. and 5/17/2025 administration time 10:19 a.m. During an interview on 5/17/2025 at 9:32 a.m. with Resident 21, Resident 21 stated they had started putting the Lidocaine patch on 2 days ago and they have not removed the patch. During a concurrent observation and interview on 5/17/2025 at 9:46a.m. with Licensed Vocational Nurse 1 (LVN 1), the Lidocaine patch was observed on Resident 21's back with no date. LVN 1 stated he placed the Lidocaine patch on yesterday 5/16/2025. During an interview on 5/17/2025 at 1:54 p.m. with LVN 1, LVN 1 stated if medication is due at 9:00a.m., there is a 2-hour (hr.) time frame in which the medication can be administered 2 hrs before and after the medication due time. LVN 1 stated despite the 2-hr. time frame, the medication preferably should be given closer to 9:00 a.m. LVN 1 stated for Lidocaine patches, if the administration time is 9:00a.m., it should be administered closer to 9:00 a.m. and has to be on for 12 hrs and be off for 12 hrs as that is the usual order for Lidocaine patches. LVN 1 stated the Lidocaine patch observed on Resident 21 was supposed to be removed during the night shift per physician's orders. LVN 1 stated leaving the Lidocaine patch on longer than 12 hrs is not good for the skin as it can cause irritation. During a concurrent interview and record review on 5/18/2025 at 12:15p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated medication can be administered upto one hour before and upto one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 10 of 23 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 05/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hour after the scheduled administration time. RNS 1 stated Lidocaine patches are on for 12 hrs and off for 12 hrs and indicated the Lidocaine patch would be administered at 9:00 a.m. and removed at 9:00p.m. RNS 1 stated leaving the Lidocaine patch on for longer than 12 hrs may irritate the skin and cause the skin to break down. RNS 1 stated the MAR dated 5/1/2025 - 5/31/2025 that indicated the Lidocaine patch to be applied to the low back topically in the morning and remove at bedtime should reflect the removal time of the Lidocaine patch and the way the MAR is documents needs to be clarified with the physician. During an interview on 5/18/2025 at 8:31p.m., with the DON, the DON stated medications are administered one hour before and after and Lidocaine patches are left on for 12 hrs and are off for 12 hrs. The DON stated the Lidocaine patch is removed after 12 hrs as that is the dosage for pharmacy. During a review of the facility's policies and Procedures (P&P), titled Administering Medications, revised dated April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 11 of 23 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 05/18/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 25 total opportunities yielded a medication error rate of 8%, in 1 of 4 sampled residents (Residents 1) observed during medication administration (med pass). Residents Affected - Some This deficient practice of med pass error rate at 8% exceeded the 5 % threshold and had the potential of adversely affecting residents' health condition. Findings: During medication administration (med pass) observation on 5/18/2025 at 8:30 a.m, in Resident 1's room, Licensed Vocational Nurse (LVN) 4 prepared 11 medications for Resident 1. The medications included one tablet of chewable aspirin 81 milligrams (MG- unit of measurement) and one tablet of hydrocodone-acetaminophen (strong pain medication) tablet 5-325 MG for Resident 1's reported seven out of 10 pain level. Resident 1 was observed swallowing both tablets. During an interview on 5/18/2025 at 8:30 a.m. with Resident 1, Resident 1 stated he did not chew any of the medications; he swallowed all his medication. During an interview on 5/18/2025 at 8:31 a.m. with LVN 4, LVN 4 stated resident did not chew the medication. LVN 4 stated not chewing the medication as ordered could alter the medication's effectiveness. 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 cerebral infarction (stroke - loss of blood flow to a part of the brain) and osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 1 had moderate cognition (ability to learn, reason, remember, understand, and make decisions) impairment with the ability to recall information, required supervision when eating, required maximal assistance (helper does more than half of the effort) for dressing, and was dependent (helper does all of the effort) for showering and bathing. During a review of Resident 1's Physician Order Summary, the Order Summary indicated Resident 1 had an order for: a.Aspirin tablet chewable 81 MG- give one tablet by mouth one time a day for cerebral vascular accident (CVA) prophylaxis (prevention) with start date 5/5/2025 b.Hydrocodone-acetaminophen tablet 5-325 MG- give one tablet by mouth every six hours as needed for severe pain (6-10 pain level) with start date 4/3/2025 and an end date 4/20/2025. c.Hydrocodone-acetaminophen tablet 5-325 MG give one tablet by mouth every six hours as needed for moderate pain (4-6 pain level) with start date 4/20/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 12 of 23 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 05/18/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 5/18/2025 at 10:10 a.m., with Licensed vocational nurse (LVN) 4, Resident 1's order summary, medication blister pack (type of tamper evident packaging that separates medication by dose), and reconciliation count sheet were reviewed. LVN 4 stated Resident 1's order summary indicated hydrocodone-acetaminophen tablet 5-325 MG is to be given for moderate pain (4-6). LVN 4 stated the blister pack and the reconciliation count sheet indicated hydrocodone-acetaminophen 5-325 MG for severe pain (6-10). During an interview on 5/18/2025 at 2:52 p.m., with pharmacist (PHARM) 2, PHARM 2 stated when a medication order is changed or updated, the facility has to print and fax the new order to the pharmacy. PHARM 2 stated the pharmacy did not receive an updated order for Resident 1 which indicated hydrocodone-acetaminophen 5-325 MG for moderate pain (4-6). During an interview on 5/18/2025 at 7:27 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated if a medication order's parameters were changed, it should have been faxed to the pharmacy. LVN 2 stated it is the LVN's responsibility to ensure the medication blister pack has the correctly ordered dose and parameters. During an interview 5/18/2025 at 11:29 a.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated the pain medication order should have been clarified with the physician and addressed. RNS 2 stated Resident 1 was at risk for pain not being managed. During an interview on 5/18/2025 at 8:08 p.m. with the Director of Nursing (DON), the DON stated it is important for medications to be administered as ordered and within the ordered pain level parameters. The DON stated if chewable aspirin is not chewed, it can affect the absorption and efficacy. The DON stated if there is a discrepancy, the nurse should have clarified the order with the physician. The DON stated if the blister pack does not pmatch the order, it can potentially cause a medication error. The DON stated Resident 1 could be at risk for being under or over medicated. During a review of the facility's policy and procedure (P&P), titled Administering Medications, revised April 2019, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 13 of 23 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 05/18/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to administer: Residents Affected - Some 1.Hydrocodone-acetaminophen with the ordered pain level parameters for Resident 1 2.Oxycodone with the ordered pain level parameters for Resident 21. This deficient practice had the potential to under or over-medicate Resident 1 and Resident 21. Findings: During medication administration (med pass) observation on 5/18/2025 at 8:30 a.m., in Resident 1's room, the Licensed Vocational Nurse (LVN) 4 administered one tablet of hydrocodone-acetaminophen (strong pain medication) tablet 5-325 MG for Resident 1's reported seven out of 10 pain level. 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 cerebral infarction (stroke - loss of blood flow to a part of the brain) and osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 1 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment with the ability to recall information, required supervision when eating, required maximal assistance (helper does more than half of the effort) for dressing, and was dependent (helper does all of the effort) for showering and bathing. During a review of Resident 1's Physician Order Summary, the Order Summary indicated Resident 1 had an order for: a.Hydrocodone-acetaminophen tablet 5-325 MG- give one tablet by mouth every six hours as needed for severe pain (6-10 pain level) with start date 4/3/2025 and an end date 4/20/2025. b.Hydrocodone-acetaminophen tablet 5-325 MG give one tablet by mouth every six hours as needed for moderate pain (4-6 pain level) with start date 4/20/2025. During a concurrent interview and record review on 5/18/2025 at 10:10 a.m., with Licensed vocational nurse (LVN) 4, Resident 1's order summary, medication blister pack (type of tamper evident packaging that separates medication by dose), and reconciliation count sheet were reviewed. LVN 4 stated Resident 1's order summary indicated hydrocodone-acetaminophen tablet 5-325 MG is to be given for moderate pain (4-6). LVN 4 stated the blister pack and the reconciliation count sheet indicated hydrocodone-acetaminophen 5-325 MG for severe pain (6-10). During an interview on 5/18/2025 at 2:52 p.m., with pharmacist (PHARM) 2, PHARM 2 stated when a medication order is changed or updated, the facility has to print and fax the new order to the pharmacy. PHARM 2 stated the pharmacy did not receive an updated order for Resident 1 which indicated hydrocodone-acetaminophen 5-325 MG for moderate pain (4-6). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 14 of 23 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 05/18/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/18/2025 at 7:27 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated if a medication order's parameters were changed, the new parameters should have been faxed to the pharmacy. LVN 2 stated it is the LVN's responsibility to ensure the medication blister pack has the correctly ordered dose and parameters. During a concurrent interview and record review 5/18/2025 at 11:29 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 1's May 2025 Medication Administration Record (MAR) was reviewed. RNS 2 stated Resident 1 received hydrocodone-acetaminophen 5-325 outside of the ordered pain level parameters seven times: 5/9/2025 (for pain 7/10), 5/10/2025 (for pain 7/10), 5/11/2025 (for pain 7/10), 5/15/2025 (for pain 7/10), 5/17/2025 (once for pain 10/10), 5/17/2025 (for pain 7/10), and 5/18/2025(for pain 7/10). RNS 2 stated the pain medication order should have been clarified with the physician and addressed. RNS 2 stated Resident 1 was at risk for pain not being managed. During an interview on 5/18/2025 at 8:08 p.m. with the Director of Nursing (DON), the DON stated it is important for medications to be administered within the ordered pain level parameters. The DON stated Resident 1 could be at risk for being under or over medicated. During a review of the facility's policy and procedure (P&P), titled Administering Medications, revised April 2019, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 15 of 23 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 05/18/2025 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure a banana was not placed on Resident 194's breakfast tray when the diet tag indicated Resident 194 was allergic to bananas. This deficient practice had the potential to subject Resident 194 to have an allergic reaction( an unpleasant or dangerous immune system reaction after a certain food is eaten. Findings: During a review of Resident 194's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) , oropharyngeal phase (swallowing difficulty related to mouth and throat), asthma (when a person's airway became inflamed , narrow, swell and becomes difficult to breathe) and repeated falls. During a review of Resident 194's Minimum Data Set (MDS), a resident assessment tool, dated 5/6/2025, the MDS indicated Resident 194's cognition was moderately impaired. The MDS indicated Resident 194 was dependent (helper does all the effort. Residents does none of the effort to complete the activity) with shower/ bathing self, substantial/ maximum assistance (helper lifts holds trunk or limbs and provides more than half the effort) with toilet hygiene, lower body dressing and putting on/ taking off footwear. During a record review of Resident 194's Order Summary Report (OSR), the Order Summary Report dated 4/30/2025 indicated Resident 194 was allergic to avocado, banana and strawberries. During a breakfast tray line observation and interview on 5/17/2025 at 7:59 a.m. with the Dietary Aide (DA), DA observed ½ of a banana on Resident 194's breakfast tray . The DA stated he was nervous and did not see the allergy sign on resident's tray. The DA stated if the resident gets the banana and eats it his health can be affected . DA stated the process is we must pay attention the allergy tag written in red double check the foods on the tray to prevent errors. During an observation and interview on 5/17/20256 at 8:15 a.m., with the Dietary Supervisor (DS), the DS stated the DA checks the meal cart to make sure Resident who are allergic to foods do not get them. The DS stated he also checks the trays . The DS stated it is important to make sure you do not put foods residents are allergic to on their food tray it because could make the resident sick. During a review of the facility's policy and procedure (P&P) titled Food Allergy and Food Intolerances dated 2001, the P&P indicates residents with food allergies and/or intolerances are identified upon admission and offered food substitutions od similar appeal and nutritional value, Steps are taken to prevent resident exposure to the allergens. Meals for residents with severe food allergies are specially prepared so that cross- contamination with allergens does not occur. During a review of the facility's policy and procedure (P&P) titled Tray identification dated revised April 2007 indicates the food service Manager or supervisor will check trays for correct diets before the food carts are transported to their designated area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 16 of 23 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 05/18/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA: committee that focuses on identifying and addressing quality deficiencies in resident care) failed to implement and ensure effective oversight of the facility and implementation of their Quality Assurance and Performance Improvement (QAPI: systemic approach to improve the quality of care and services provided to residents) plan. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents. During a concurrent interview and record review on 5/18/2025 at 6:25p.m., with the Administrator (ADM), the ADM stated they have QAPI meetings monthly and QAPIs are structured to identify potential solutions to yield positive outcomes. The ADM stated they did not have documentation of QAPI meetings prior to March 2025. The ADM stated there were issues regarding call light response time at the end of February 2025, and in March 2025, call light issues were present during the resident council meetings, so a QAPI was implemented regarding call light response times. The ADM stated there were no other issues that they were aware of for March 2025 and indicated skin integrity issues were identified at a later time. The ADM stated when he took over as the ADM in January 2025, upon observing trends, he provided additional nursing support [Assistant Director of Nursing (ADON)] to help with care and support and to see if any changes would be made. ADM stated the QAPI was initiated in March 2025 as he wanted to give the previous Director of Nursing (DON) the benefit of the doubt on her opinions and believed it was not necessary to do a QAPI at the time when the trends were present and indicated it could have helped if a QAPI was initiated at that time. During a concurrent interview and record review on 5/18/2025 at 6:39 p.m. with the ADM, the ADM stated there is no QAPI in April 2025 and indicated the call light issue has not been resolved in April. The ADM stated during the resident council meeting; the residents did not complain about call lights. ADM stated he looked through the Director of Nursing (DON)'s office and was not able to locate previous QAPI documents. ADM stated if a QAPI is not implemented, the trend identified will continue and impose more risks to the residents and not enhancing care. ADM stated the QAPI is not complete. ADM stated the QAPI is constantly monitored each day and indicated if an issue continues to trend, it will be added to the QAPI. During a review of the facility's policy and procedure (P&P) titled, Quality Assessment and Performance Improvement (QAPI) Program, revised on February 2020, the P&P indicated this facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. provide a means to establish and implement performance improvement projects to correct identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 17 of 23 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 05/18/2025 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 0867 negative or problematic indicators. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Few reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. establish systems through which to monitor and evaluate corrective actions. Authority: 1. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program. 2. The governing board/owner evaluates the effectiveness of its QAPI program at least annually and presents findings to the QAPI committee. 3. The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. Implementation 1. The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 18 of 23 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 05/18/2025 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 0867 c. Level of Harm - Minimal harm or potential for actual harm identifying and prioritizing quality deficiencies; d. Residents Affected - Few systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitoring QAPI-related activities and make adjustments to the plan. During a review of the facility's P&P titled, Quality Assessment and Performance Improvement (QAPI) Program - Analysis and Action, revised on March 2020, the P&P indicated quality deficiencies that are identified through feedback and data and will undergo appropriate corrective action. Corrective actions are monitored against established goals and benchmarks by the QAPI committee. The QAPI program, overseen the QAPI committee is designed to identify and address quality deficiencies through the analysis of underlying cause and actions targeted at correcting systems at a comprehensive level. The methodology for analysis and action is guided by a written QAPI plan that includes: a. Definition of the problem, based on information obtained through data, self-assessment and feedback systems. b. An analysis of the root cause of the problem from a systems perspective. c. Establishing measurable goals or benchmarks for improvement. d. Specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 19 of 23 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 05/18/2025 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 0867 e. Level of Harm - Minimal harm or potential for actual harm Methods and frequency of monitoring performance improvement objectives. Residents Affected - Few The QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and reporting findings to the administrator and governing board. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 20 of 23 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 05/18/2025 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 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** . Residents Affected - Some Based on observation, interview, and record review, the facility failed to implement their Enhanced Barrier Precaution (EBP: infection control practices to prevent the spread of multidrug-resistant organisms (MDRO's) control measures for one of three sampled residents (Residents 21 ) by failing to wear proper Personal Protective Equipment (PPE: to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when coming in contact with /administering Resident 21's Lidocaine Patch (medication that numbs specific area of the body by blocking pain signals to the brain) and when handling the indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified fracture (break in a bone) of unspecified lumbar vertebra (one of the bones that make up the spinal column in the lower back), spinal stenosis (space inside the backbone is too small putting pressure on the spinal cord), and obstructive (urine flow is blocked) and reflux uropathy (occurs when urine flows backward into the bladder often as a result of obstruction). During a review of Resident 21's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21 Minimum Data Set [MDS] a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 21'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 21 was dependent on chair/bed-to-chair transfer and toileting hygiene, required maximal assistance (provide more than half the effort) for bathing, dressing upper (above waist) and lower (waist below) body, required supervision on personal hygiene and oral hygiene, and required set up for eating. The MDS indicated Resident 21 utilizes a wheelchair and has bilateral (both sides) impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 21's Order Summary Report (physician orders) dated 5/18/2025, the order summary indicated enhanced barrier precautions during high contact resident care activities secondary to (foley cath) every shift with an active date of 4/18/2025. During an observation on 5/17/2025 at 9:46 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed exposing Resident 21's Lidocaine patch located on the lower back without wearing proper PPE. LVN 1 was then observed touching Resident 21's foley catheter bag without wearing proper PPE. During an interview on 5/17/2025 at 1:54 p.m., with LVN 1, LVN 1 stated EBP's are for residents with wounds and foley catheters, and gowns are worn when performing nursing care that can possibly expose you to fluids or wounds. LVN 1 stated when giving medications, gowns are not worn since you are not giving direct patient care. LVN 1 stated gowns are worn when you have direct patient skin to skin contact and when emptying the foley catheter bag. LVN 1 stated as long as there is a possibility of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 21 of 23 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 05/18/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some liquid or splashing during nursing care, a gown is worn. LVN 1 stated if gowns are not worn, whatever is being handled such as bodily fluids can splash and wearing a gown can prevent that from occurring. During an interview on 5/18/2025 at 10:41a.m. with the Infection Preventionist Nurse (IPN), the IPN stated EBPs are for residents who have foleys, gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), or chronic wounds that require dressing. The IPN stated high contact includes providing activities of daily living (ADL: shower, bed bath) care and emptying the foley bag. The IPN stated a gown should be worn if you are touching the foley bag even if you are not emptying it as it might spill. The IPN stated you wear the gown to protect yourself and the resident and not wearing a gown can contaminate your clothing and increase the chance of spreading it to other residents. During an interview on 5/18/2025 at 1:59 p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated PPE should be worn since you are coming in contact with the resident when putting on the Lidocaine patch as it is worn for precaution. During an interview on 5/18/2025 at 8:31p.m., with the Director of Nursing (DON), the DON stated EBPs are for residents that have some kind of invasive device like a foley catheter and staff should wear a gown when you are going to anticipate having contact with the resident. The DON stated a gown is worn to protect the residents. The DON stated a gown is worn when applying a Lidocaine patch on a resident who is on EBP because you are having contact with the patient. During a review of the facility's policies and Procedures (P&P), titled Administering Medications, revised April 2019, the P&P indicated staff follows stablished facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a review of the facility's P&P titled Enhanced Barrier Precautions, revised December 2024, the P&P indicated enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. Enhanced barrier precautions apply when a resident has a wound or indwelling medical device, and has secretions or excretions that are unable to be covered of contained. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a.Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 22 of 23 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 05/18/2025 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two of 20 resident bedrooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room. This deficient practice had the potential to result in inadequate space to provide privacy, space during daily care, and access during an emergency. During a review of the facility's Client Accommodations Analysis form, provided by the facility on 5/18/2025, the facility had 2 rooms that measured less than 80 sq. ft. per resident in multi-bed rooms and two rooms that measured less than 100 sq. ft for a single bedroom. The resident rooms were as follows: room [ROOM NUMBER]: 14 inches (in: unit of length) x 10.1 in [141.4 sq. ft.] approved capacity: 2 room [ROOM NUMBER]: 14 in x 10.7 in [149.8 sq. ft.] approved capacity: 2 During a concurrent observation and interview on 5/18/2025 at 8:43a.m. with Maintenance Supervisor (MS), the room size measured for 5 was 14 in x 10.7 in and room [ROOM NUMBER] was 14 in x 10.6 in. MS stated he does not know what the right measurement for each resident is and indicated the room is small for 2 beds. MS stated there is a room waiver that is submitted for the rooms and indicated if the room is small, the staff and residents may bump into things. During an interview on 5/18/2025 at 8:40p.m. with Director of Nursing (DON), DON stated if the resident's room is deemed too small per guidance, there is potential for the room to be cluttered and the resident may fall due to not having enough space. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 23 of 23