Health inspection·July 15, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Treatment dated 6/3/2025, The PT Evaluation and Plan of Treatment indicated Resident 1 was referred to PT for assessment of her BLE range of motion [(ROM] the direction a joint can move to its full potential), strength, balance, motor coordination, motor control, gait mechanics, functional mobility, safety awareness and risk for falls due to Resident 1's fall risk, seizures, altered mental status (AMS). During a review of Resident 1's Change of Condition (COC) Evaluation dated 6/20/2025, the COC Evaluation indicated Resident 1 had an unwitnessed fall and was found sitting on her bottom on the floor with her back facing the side of her bed, with her left leg folded under her, her right leg straight with her right foot flat on the floor. The COC Evaluation indicated Resident 1 reported to LVN 1 that she did not know what happened. During a review of Resident 1's Rehab Status Post-Fall Screen dated 6/20/2025, the Rehab Status Post-Fall Screen indicated Resident 1 was found in her room on the floor. The Rehab Status Post-Fall Screen indicated Resident 1 was unable to recall a what happened due to her impaired cognition, cognitive issues, and poor safety awareness with impulsive tendencies. The Rehab Status Post-Fall Screen indicated a recommendation for bed and chair alarms: (bed alarms and chair alarms are commonly used to alert staff if a patient is attempting to get up without assistance, especially if they have a high fall risk and can help prevent falls by providing early warning signals that prompt staff to assist the patient). During a review of Resident 1's COC Evaluation form dated 6/30/2025, the COC Evaluation form indicated Resident 1 had an unwitnessed fall where she was found in her bathroom lying on the floor using her arm to cushion her head. The COC Evaluation form indicated Resident 1 had a hematoma on the left side of her scalp. The COC Evaluation form indicated Resident 1's physician gave instructions to transfer Resident 1 to a General Aute Care Hospital (GACH) via 911 for further evaluation. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/30/2025, the SBAR indicated Resident 1 was transferred to a GACH via 911 for evaluation. During a review of the Emergency Department (ED) documents dated 6/30/2025, the ER documents indicated Resident 1 was transferred to the ED on 6/30/2025. During a review of the GACH's Discharge Instructions dated 6/30/2025, the Discharge Instructions indicated Resident 1 sustained a mild to moderate left parietal scalp hematoma/contusion, which could represent a small calcification (an abnormal buildup of calcium salts in body tissues, leading to hardening) or small acute intraparenchymal hemorrhage (bleeding from a damaged blood vessel). During an interview on 7/14/2025 at 11:51 a.m., Licensed Vocational Nurse (LVN) 1 stated on 6/30/2025 she went to Resident 1's room and noticed she was not in bed and that her bedside table was next to the bathroom, when she opened the bathroom door she found Resident 1 on the floor. LVN 1 stated she assessed Resident 1 and found a hematoma on the left side of Resident 1's head. LVN 1 stated Resident 1 should be assisted when she gets up from bed because she was unsteady when she walked. LVN 1 stated she was not aware of the recommendation for Resident 1 to use a bed alarm and using one could have prevented Resident 1 from falling because the alarm should have prompted staff to check on her. During an interview on 7/14/2025 at 1:18 p.m., the Assistant Director of Rehab (ADOR) stated on 6/3/2025 Resident 1 they assessed Resident 1 at high risk for falls. On 6/20/2025, Resident had an unwitnessed fall and was reassessed by the Rehab Depart post fall. The ADOR stated recommendations for Resident 1 included using a bed alarm and all departments were made aware of the recommendation via the facility's computer systems, and verbally during the IDT meeting. The ADOR stated with Resident 1's history of falls, anxiety, her impaired cognition, impulsive behavior and weakness to her BLEs, Resident 1 was at risk for falls and needed assistance walking and getting out of bed. During an interview with on 7/14/2025 at 3:20 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555805 If continuation sheet Page 2 of 3 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 07/15/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete identified as high risk for fall because Resident 1 had a previous unwitnessed fall on 6/20/2025. CNA 1 stated she went to Resident 1's room and on 6/30/2025 and found the resident sitting on the bathroom floor and noticed a bump on the left side of her head. CNA 1 stated no one told her about the recommended interventions to use a bed alarm and using the bed alarm might have helped prevent Resident 1's second unwitnessed fall (6/30/2025). During an interview on 7/15/2025 at 3:20 p.m., the Director of Nursing (DON) stated Resident 1 had two unwitnessed falls, since her admission on [DATE], one on 6/20/2025 and another one on 6/30/2025. The DON stated the rehabilitation department assessed Resident 1 after her first unwitnessed fall on 6/20/2025 and recommended that a bed alarm was to be used. The DON stated although the Rehab Depart made a recommendation for Resident 1 to use a bed alarm, it did not mean the intervention would be used. The DON acknowledged that using the bed alarm might have prevented Resident 1 from falling the second time (6/30/2025). During a review of the facility s Policy and Procedure (P/P) titled, Falls and Fall Risk, Managing revised 3/2018, the P/P indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls may include cognitive impairment, lower extremity weakness, functional impairment and incontinence. Medical factors that contribute to the risk of falls may include neurological disorders. The staff with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. During a review of the facility's undated P/P titled, Fall Risk Assessment the P/P indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Event ID: Facility ID: 555805 If continuation sheet Page 3 of 3