Other·March 9, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of an Entity Reported Incident (ERI). ERI Number: CA00551097 Representing the Department of Public Health: Surveyor ID: 38550 RN, HFEN The inspection was limited to the specific ERI investigated and does not represent a full inspection of the facility. One deficiency was issued for ERI Number: CA00551097

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555805 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEL VISTA HEALTHCARE CENTER 5001 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow the resident's plan of care and its policy and procedures related to resident transfers for one of two sampled residents (Resident 1). Resident 1, who had a history of osteoporosis (a condition that causes bones to become weak and brittle), was not being transferred as per the policy and the plan care to prevent fractures. As a result of the staff not following the resident's plan of care and the facility's policy, Resident 1 sustained a fracture (broken bone) to the right leg/knee. Findings: On September 14, 2017 at 9:17 a.m., during an observation, Resident 1 was awake, lying in bed, with a green-brown discoloration to the left FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555805 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEL VISTA HEALTHCARE CENTER 5001 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE leg. A leg brace was observed on the resident's right leg. A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on June 9, 2017. The resident's diagnoses included multiple fractures, osteoporosis, osteoarthritis (a type of joint disease that results from breakdown of joint cartilage and underlying bone), kyphosis (excessive outward curvature of the spine, causing hunching of the back), scoliosis (a medical condition in which a person's spine has a sideways curve), Cushing's Syndrome (a hormonal condition that involves many areas of the body and causes symptoms such as thinning of the skin, weakness, bruising and thin weak bones). A review of Resident 1's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated June 16, 2017, indicated Resident 1's cognition (thought process) was intact. The MDS indicated Resident 1 used a wheelchair, required a two-person physical assist for all transfers and was totally dependent on staff for locomotion inside and outside of the facility. A review of Resident 1's Care Plan, dated June 14, 2017, indicated the resident had a self-care performance deficit and required total assistance of a two-person physical assist when transferring. A review of Resident 1's Care Plan, dated August 14, 2017, indicated the resident had multiple rib fractures and was at risk for repeated fractures. The staff's interventions included handling the resident gently when moving or positioning and maintaining the resident's body alignment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555805 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEL VISTA HEALTHCARE CENTER 5001 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Physical Therapy ([PT] healthcare specialty that includes the evaluation, assessment, and treatment of individuals with limitations in functional mobility) Note, dated August 21, 2017, and timed 2:17 p.m., indicated the resident had a weak trunk control due to pain in the ribs and needed increased assistance with sitting and transferring. A review of Resident 1's PT Note, dated August 22, 2017, indicated PT 1 accompanied the resident to an appointment. The note indicated the resident was totally dependent on staff and required a two-person assist with transferring from low to high surfaces. A review of Resident 1's Nurse Progress Note, dated August 23, 2017, and timed 8:34 p.m., indicated the resident was observed to have swelling and tenderness to the right knee. A review of Resident 1's Nurse Progress Note, dated August 30, 2017, and timed 6:40 p.m., indicated the resident's family member (FM 1) was upset and wanted the resident to be seen by the orthopedic doctor (a doctor specializing in bones and joints) sooner than the appointment that was scheduled for September 15, 2017. FM 1 wanted the resident to be transferred to a hospital's emergency room for evaluation of the resident's continued knee swelling. A review of Resident 1's Nurse Progress Notes, dated August 30, 2017, and timed 8:15 p.m., indicated the resident was transferred via ambulance to a General Acute Care Hospital (GACH) for further evaluation of the resident's right knee swelling and redness. A review of Resident 1's PT note, dated August 31, 2017, indicated the resident's progress was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555805 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEL VISTA HEALTHCARE CENTER 5001 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE slow during the week of August 22, 2017 through August 28, 2017, due to the resident reporting increased right knee discomfort and edema. A review of the GACH's Diagnostic Radiology Report, dated August 30, 2017, and timed 9:58 p.m., indicated the resident had a right knee Xray (a test that produces images of the structures in the body, such as bone). The results of the X-ray indicated the resident had a non-displaced intra-articular fracture of the medial tibial plateau (a break in the upper part of the shinbone that involves the knee joint). A review of Resident 1's Nurse Progress Notes, dated August 31, 2017, and timed 7:52 a.m., indicated the resident was transferred from the GACH back to the facility at 2:20 a.m. on August 31, 2017. The resident was diagnosed with a right knee effusion (swelling of the knee that occurs when excess fluid accumulates around the knee joint) and had 50 milliliters of fluid drained from the right knee. A review of Resident 1's Nurse Progress Note, dated August 31, 2017 and timed 10:01 a.m., indicated the facility received a call from the GACH and was informed that the resident had a right tibial plateau fracture and needed to be sent back to the GACH for a splint (a strip of rigid material used for supporting and immobilizing a broken bone) placement. A review of the facility's investigation report, dated August 31, 2017, and timed 11:58 a.m., indicated PT 1 reported that he blocked Resident 1's knee with his knee for leverage during transferring. The report indicated that the repetitive transfers from wheel chair to the van and to the bone scan table may have caused micro trauma to the resident's knee. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555805 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEL VISTA HEALTHCARE CENTER 5001 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On September 14, 2017 at 10 a.m., during an interview, PT 1 stated that he accompanied the resident to an appointment for a bone scan (a test used to diagnose and track several types of bone disease) on August 22, 2017 to assist the resident with transferring to and from the wheelchair. PT 1 stated that while transferring the resident, he blocked Resident 1's knee by placing his knee against the resident's right knee, and pivoted the resident from the wheelchair to the car. PT 1 stated that on August 22, 2017 this technique was used to transfer the resident about four to five times over the span of two hours. PT 1 stated that he always used the knee block technique to transfer the resident. At 10:37 a.m., on September 14, 2017, during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 always required a two- person assist for transferring with a Hoyer lift (mechanical lifting device). On September 14, 2017 at 3 p.m., during an interview, the Director of Nursing (DON) stated they work with PT to determine the type of precautions and transfers that a resident should have. Initially, Resident 1 was a twoperson manual assist and after the resident sustained rib fractures, the resident was changed to a two-person assist with a Hoyer lift (a mechanical device used to lift and transfer residents). The DON stated that when transferring a resident, "physical therapy might use other modalities such as manually transferring the resident." A review of a facsimile received from the DON on September 15, 2017, indicated the facility did not have a policy and procedure for the type of transfers used by PT that was not part of Resident 1's plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555805 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEL VISTA HEALTHCARE CENTER 5001 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On September 26, 2017 at 1:30 p.m., during a telephone interview, the physician (MD 1) stated that Resident 1 was very fragile and that the best way to transfer the resident would be using a Hoyer lift. A review of the facility's policy and procedure titled, "Safe Lifting, Transfer, and Movement of Residents" dated March 16, 2015, indicated nursing and physical therapy staff would assess the resident's needs for transfer assistance on an ongoing basis and staff would document the resident's needs in the care plan. The policy indicated mechanical lifting devices would be used for heavy lifting, including the lifting and transferring residents. A review of the facility's undated policy and procedure titled, "Care Plans-Comprehensive," indicated the resident's care plan was based on a comprehensive assessment and was designed to assist in preventing declines in the resident's functional status and/or functional levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 585311 Facility ID: CA940000010 If continuation sheet 7 of 7