Health inspection·June 18, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity by failing to ensure Resident 1 was assisted with getting dressed prior to him leaving for his appointment. This deficient practice resulted in Resident 1 to feel embarrassed because he had to wear a hospital gown (a loose-fitting garment, typically open in the back, that patients wear in medical facilities) to his appointment. This deficient practice had the potential for Resident 1 to be exposed causing unworthiness and psychosocial harm to Resident 1. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure ([AKI] also called acute kidney injury - when the kidneys suddenly can't filter waste products from the blood), type 2 diabetes ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 1's cognition was intact. During a telephone interview on 6/17/2025 at 1:56 p.m., with Resident 1's Family Member (FM 1), FM 1 stated on 5/30/2025 at 7:30 a.m., she brought Resident 1 street clothes (ordinary clothes that people wear in public) to wear to his appointment. FM 1 stated when Resident 1 arrived at his appointment, he was still wearing a hospital gown and not the street clothes she brought for him to be changed into. FM 1 stated she was upset because Resident 1 expressed to her that he was embarrassed because he had to wear a hospital gown in public. During an interview on 6/18/2025 at 11:46 a.m., with the Case Manager (CM), the CM stated she received a phone call (after Resident 1's appointment on 5/30/2025) from Resident 1's FM 1 complaining that Resident 1 arrived at his appointment wearing a hospital gown. The CM stated CNA 1 reported to her that Resident 1 had refused to change into his clothes. During a concurrent interview and record review on 6/18/2025 at 3:26 p.m., with the Case Manager (CM), Resident 1's Clinical Records dated 5/2025 were reviewed. The Clinical Records indicated, there were no documentation indicating on 5/30/2025 that Resident 1 refused to change into his street Page 1 of 2 555805 555805 06/18/2025 Bel Vista Healthcare Center 5001 East Anaheim Street Long Beach, CA 90804

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clothes prior to him leaving for his appointment. The CM indicated she did not find any documentation on Resident 1's refusal to change into his street clothes nor that the facility staff notified his RP 1 of his refusal to change into his clothes. During a telephone interview on 6/18/2025 at 4:19 p.m., with CNA 1, CNA 1 stated on 5/30/2025, she offered Resident 1 only once if he wanted to change into his clothes prior to leaving to his appointment. CNA 1 stated Resident 1 refused to be changed because he was hot. CNA 1 admitted to not reporting Resident 1's refusal to change into his clothes. CNA 1 stated she should have offered Resident 1 to be changed at least three times and if he still refused, she would notify the charge nurse immediately. During an interview on 6/18/2025 at 4:51 p.m., with the Director of Nursing (DON), the DON stated CNA 1 should have changed Resident 1 into his clothes prior to leaving for his appointment. The DON stated if a resident refused to be changed into their clothes, it should be documented in the medical record and the licensed nurses should have notified of his refusal. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to dress in clothing that they prefer. During a review of the facility's P&P titled Resident Rights, dated 2/2021, the P/P indicated employees shall treat all resident with kindness, respect and dignity. 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 and be treated with respect, kindness and dignity. 555805 Page 2 of 2