Bellflower Post Acute

F-F812

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45777 potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Some a. Ensure Resident 7's, foley catheter ( a thin, flexible tube inserted into the bladder [an organ that stores urine] to drain urine) was not touching the floor.

b.Ensure facility staff used the correct Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs) when caring for one of two sampled residents (Resident 15) that was on Enhanced Barrier Precautions (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs)) and not performing hand hygiene prior to entering room.

c. Ensure the facility staff had access to PPE

d. Conduct annual Legionella (a severe form of lung infection that causes lung inflammation caused by bacteria) facility risk assessment.

These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infections for the residents.

During a review of Resident 7's Admission Record, the Admission Record indicated Resident 7 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including primary hypertension (high blood pressure) retention of urine, unspecified (when person is unable to completely empty the bladder) and difficulty in walking, not elsewhere classified.

During a review of Resident 7's History and Physical (H&P), dated 12/11/2025, the H&P indicated, Resident 7 had the capacity to make decisions.

During a review of Resident 7's Minimum Data Set (MDS- a resident screening tool) dated 1/29/2025, the MDS indicated, Resident 7 required partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort with lower body dressing, putting on/taking off footwear, shower/bathe self and Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity upper body dressing and sit to stand.

During a review of Resident 7's Order Summary Report (OSR) dated 1/1/2025 , the OSR indicated foley catheter French 20 (size of the catheter / 10 cc (balloon that can be inflated with 10 milliliters of water to secure it within the bladder).

During a record review of Resident 7's undated Care Plan titled Foley Catheter, the Care Plan indicated to place all tubing without touching the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 During an initial observation and interview on 2/18/2025 at 11:55 a.m., in the activity room. Resident 7 was observed sitting in his wheelchair alert and oriented the foley catheter tubing was hanging from Resident 7's Level of Harm - Minimal harm or right pant leg the catheter bag was attached to the back of his wheelchair and the tubing was lying on the potential for actual harm floor. Licensed Vocational Nurse 4 (LVN 4) observed the catheter was on the floor and stated it is nurses' responsibility to make sure the foley catheter is off the floor before taking the resident from his room, LVN 4 Residents Affected - Some stated that dragging the foley catheter tubing on the floor can cause the tubing to break and spill urine on the floor this can cause the spread of infection to the residents.

During an interview on 2/18/2025 at 11:55 a.m., with LVN 2, LVN 2 indicated Certified Nurse Assistants (CNA), Licensed Vocational Nurses (LVN) and Treatment Nurses (TN) are responsible for making sure the foley catheter bag is below the bladder and make sure the tubing is not resting on the floor. LVN 2 stated this is an infection control issue, and one can spread germs causing the resident to get an infection.

During an interview on 2/20/2025 at 4:29 p.m., with the Director of Nursing (DON) , the DON stated when working with foley catheter tubing's staff need to make sure they are hanging the drainage bag below the bladder, ensure there are no kinks in the tubing and do not place it on floor because there is a risk for infection .

b/cDuring a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia (difficulty swallowing), and Huntington's Disease (a progressive inherited neurodegenerative disorder that affects the brain).

During a review of Resident 15's H&P dated 6/22/2024, the H&P indicated Resident 15 did not have the capacity to understand and make decisions.

During a review of Resident 15's MDS dated [DATE REDACTED], the MDS indicated Resident 15's cognitive skills were severely impaired. The MDS indicated Resident 15 was dependent on all aspects of activities of daily living (ADL: bathing, chair/bed-to-chair transfer, personal hygiene, toileting hygiene, oral hygiene).

During a concurrent observation and interview on 2/20/2025 at 9:52 a.m. with LVN 3, LVN 3 did not perform hand hygiene prior to entering Resident 15's room,LVN 3 put on gloves, and went to Resident 15's bed. Resident 15's g-tube feeding was running. Resident 15 had an abdominal binder ( devide that wraps around

the abdomen). LVN 3 stated Resident 15 was on EBP due to having a g-tube. LVN 3 stated she wore a gown when she passed medications, provided ADL's, and for residents that have a g-tube, a foley catheter, or open wounds. LVN 3 stated she should have been wearing a gown when observing Resident 15's g-tube. LVN 3 stated not wearing PPE exposes staff to more bacteria. LVN 3 stated the PPE was not easily accessable because they were not placed outside rooms that have reesidents on EBP. LVN 3 stated the gowns are at the front of Nursing Station 1 in the linen cart. LVN 3 stated she should perform hand hygiene when she gives eye drops, medications, when changing gloves, and before and after patient care. LVN 3 stated the purpose of hand hygiene is for infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 During an interview on 2/20/2025 at 3:19p.m., with the Director of Staff Development (DSD), the DSD stated gowns are kept in the front of Nursing Station 1, in the middle of the hallway, and at the back where Nursing Level of Harm - Minimal harm or Station 2 is located. The DSD stated gowns are worn when they provide direct patient care, but when potential for actual harm answering the call light or talking to the resident, gowns are not necessary. The DSD stated if one is observing a g-tube or a resident has a foley, a gown should be worn to protect the resident and staff. as it is Residents Affected - Some an additional. The DSD stated hand hygiene is performed before entering and after exiting the residents' room and prior to wearing gloves to prevent spread of infection.

During an interview on 2/20/2025 at 4:46 p.m., with the Director of Nursing (DON), the DON stated hand hygiene is important and not performing hand hygiene will give residents an infection as hands touch many things and can cause cross contamination. The DON stated if a resident has a g-tube, Staff are supposed to wear a gown as part of the infection control precautions. The DON stated PPE should be easily accessible as it promotes compliance with infection control when the PPE is stored close to the rooms, if that resident is

on infection control precaustions such as EBP.

d. During a concurrent interview and record review of the water management program on 2/19/2025 at 3:39 p.m., with the Administrator (ADM), the ADM stated they do not have the facility's Legionella Risk Assessment for 2024.

During an interview on 2/20/2025 at 4:45 p.m. with the DON, the DON stated Legionella prevention is important since the facility population are elderly and have lowered resistance to infections and can increase their risk for infection. The DON stated if the policy indicated to do a Legionella Risk Assessment, the policy should be followed.

During a review of the facility's policies and Procedures (P&P), titled Indwelling Catheter Care revised 3/2021, the P&P indicated the catheter tubing must remain patent, with the drainage bag kept below the level of the bladder to maintain unobstructed urine flow and prevent pooling and back flow of the urine into the bladder. The drainage bag should be kept off the floor. The drainage bag should be placed in a privacy dignity bag.

During a review of the facility's P&P, titled Enhanced Standard Precautions, revised 5/2024, the P&P indicated standard precautions will be used in care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. Wera a gown that is appropriate to the task you are performing.

During a review of the facility's policies and Procedures (P&P), titled Hand Hygiene, revised 7/2019, the P&P indicated it is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible,

the spread of infection. Hand hygiene will be performed by staff as follows: before touching a resident; if gloves will be worn, before gloving.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 During a review of the facility's P&P, titled Policy for Legionnaire's Disease (Legionella Pneumophila), revised 6/2017, the P&P indicated the facility will complete a Legionella Risk Assessment to determining Level of Harm - Minimal harm or their risk for Legionella outbreaks. This assessment will be completed annually. potential for actual harm 46415 Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44055 potential for actual harm Based on observation, interview, and record review, the facility failed to offer and monitor the immunization Residents Affected - Some (a process whereby a person is made resistant to a disease through medication administration) status for the Influenza (flu: a contagious respiratory illness) and Pneumococcal (bacterial infection that causes serious lung infections) vaccinations (medication to prevent a particular disease) for one of five sampled residents (Resident 9).

This deficient practice resulted in Resident 9's medical records being incomplete.

Findings:

During a review of Resident 9's Admission Record, the Admission Record indicated Resident 9 was admitted to the facility on [DATE REDACTED] with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), cerebral palsy (group of disorders that affect muscle tone and movement), and asthma (chronic lung disease that causes inflammation in the airway).

During a review of Resident 9's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 9 does not have the capacity to understand and make decisions.

During a review of Resident 9's Minimum Data Set [MDS] a resident assessment tool), dated 12/23/2024, the MDS indicated Resident 9 's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were moderately impaired. The MDS indicated Resident 9 was dependent on all aspects of activities of daily living (ADL: bathing, chair/bed-to-chair transfer, personal hygiene, toileting hygiene, oral hygiene). The MDS indicated Resident 9 had impairments on both of the upper (arms/shoulders) extremities.

During a review of the Immunization History Report dated 2/19/2025, the immunization history report indicated Resident 9 had no record of having received the flu or the pneumococcal vaccines (PCV).

During an interview on 2/19/2025 at 4:11p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the PCV are offered within seven (7) days of admission and verifying records by speaking to the family, or by looking at the California Immunization Registry (CAIR: web-based database that stores immunization records of children and adults) to check the immunization status for the resident. The IPN stated her PCV spreadsheet for the residents was not up to date and has residents that have already been discharged . The IPN stated if the PCV is offered they would document it, and if the resident declined the PCV, they would offer it again within 90 days.

During a concurrent interview and record review on 2/19/2025 at 4:33 p.m. with the IPN, the spreadsheet (influenza vaccination tracker) undated was reviewed. The IPN stated Resident 9 is not listed on her spreadsheet (vaccine) that lists the PCV statuses of the residents. The IPN stated she would have offered

the vaccines at admission and indicated vaccinations are important as the residents are vulnerable, and it is to protect the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 0883 During an interview on 2/20/2025 at 4:48p.m. with Director of Nursing (DON), the DON stated residents have to have updated immunizations and records as they are at higher risk for infection. The DON stated the PCV Level of Harm - Minimal harm or vaccine is offered upon admission, and if the resident has not received the PCV vaccine, they have to try and potential for actual harm offer the vaccine.

Residents Affected - Some During a review of the facility's policies and Procedures (P&P), titled Pneumonia Vaccine for Residents, revised 1/2024, the P&P indicated it is the policy of the facility to offer residents pneumonia vaccine in accordance with the latest U.S. Department of Health and Human Services, Centers for Disease Control and Prevention recommendations (CDC). On admission, all residents will be evaluated for pneumococcal vaccination status. Before offering the pneumococcal immunization, each resident of their responsible party will receive education regarding the benefits and potential side effects of immunization. Each resident will be offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. The resident's clinical record should include documentation that the resident or their responsible party was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal. The pneumonia vaccination status of the resident will be determined, and vaccines will be offered as recommended by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention recommendations (CDC).

During a review of the facility's P&P, titled Flu (Influenza) Vaccination for Residents, revised 1/2024, the P&P indicated it is the policy of the facility to offer residents flu (influenza) vaccine yearly, in accordance with the newest recommendations. On admission, all residents will be evaluated for flu (influenza) vaccination needs.

The flu (influenza) vaccination status of the resident will be determined, and vaccines will be offered as follows: the resident's clinical record should include documentation that indicates that the resident or their representative was provided education regarding the benefits and potential side effects of the immunization and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications, refusal or had received it prior to admission.

46415

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 46415

Residents Affected - Few Based on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status.

This failure had the potential to place staff and residents at risk for negative health outcomes such as being hospitalized due to COVID-19.

Findings:

During a concurrent interview and record review of the Covid-19 Staff Vaccination Status (document that reflects staff employee vaccination status) on 2/19/2025 at 4:36 p.m., with the Infection Prevention Nurse (IPN), the IPN stated she does not know the facility physicians and consultants Covid-19 immunization status.

During an interview on 2/20/2025 at 4:42 p.m., with the Director of Nursing (DON), the DON stated the Covid-19 vaccination status for all employees including doctors, rehabilitation departments, and consultants that come in contact with residents must be known as they put the residents they are incontact with at risk for contracting infections.

During a review of the facility's policy and procedure (P&P) titled, Coronavirus Vaccine Policy (COVID-19 Vaccine Policy), dated 2/2025, the P&P indicated staff: for the purposes of this policy, staff refers to any individual that works or volunteers in the facility at least once a week. This includes individuals under contract or arrangement (e.g., medical directors, hospice and dialysis staff, therapists, mental health professionals, or volunteers). The facility will maintain documentation for all residents and staffs on Covid-19 vaccination status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44055

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure 20 of 29

resident rooms (Rooms 1 to 7, 11 to 14, 19, 23-29) met the requirements of 80 square feet for each resident

in multiple resident bedrooms. The 20 rooms consisted of two beds in each bedroom.

This deficient practice had the potential to limit space to provide nursing care, and limit privacy for residents.

Findings:

During a review of the facility's Client Accommodations Analysis form, submitted 2/18/2025, the form indicated the following resident rooms measured:

room [ROOM NUMBER] (2 beds) 155.76 total, 77.88 square footage per resident

room [ROOM NUMBER] (2 beds) 153.4 total, 76.8 square footage per resident

room [ROOM NUMBER] (2 beds) 146.72 total, 73.36 square footage per resident

room [ROOM NUMBER] (2 beds) 148.7 total, 74.4 square footage per resident

room [ROOM NUMBER] (2 beds) 158.12 total, 79.0 square footage per resident

room [ROOM NUMBER] (2 beds) 138.32 total, 69.16 square footage per resident

room [ROOM NUMBER] (2 beds) 150.3 total, 75.2 square footage per resident

room [ROOM NUMBER] (2 beds) 150.3 total, 75.2 square footage per resident

room [ROOM NUMBER] (2 beds) 143.2 total, 71.6 square footage per resident

room [ROOM NUMBER] (2 beds) 158.12 total, 79.0 square footage per resident

room [ROOM NUMBER] (2 beds) 158.12 total, 79.0 square footage per resident

room [ROOM NUMBER] (2 beds) 149.16 total, 74.8 square footage per resident

room [ROOM NUMBER] (2 beds) 158.6 total, 79.3 square footage per resident

room [ROOM NUMBER] (2 beds) 151.42 total, 75.71 square footage per resident

room [ROOM NUMBER] (2 beds) 152.92 total, 76.46 square footage per resident

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 055408 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055408 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bellflower Post Acute 9710 E. Artesia Ave Bellflower, CA 90706

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 room [ROOM NUMBER] (2 beds) 148.74 total, 74.37 square footage per resident

Level of Harm - Potential for room [ROOM NUMBER] (2 beds) 159.1 total, 79.6 square footage per resident minimal harm room [ROOM NUMBER] (2 beds) 141.9 total, 70.8 square footage per resident Residents Affected - Some room [ROOM NUMBER] (2 beds) 150.29 total, 75.15 square footage per resident

room [ROOM NUMBER] (2 beds) 146.52 total, 73.26 square footage per resident

The request indicated the rooms fall short of the minimum requirements, but the needs of the residents were fully accommodated. The request indicated the residents were able to move about freely, the toilets and closet space are easily accessible, and the facility was adequately equipped environmentally for comfort and privacy of residents. The request indicated there was adequate space for nursing care and residents can be quickly and safely evacuated in the event of an emergency.

During observation from 2/18/2025 to 2/20/2025 of the facility and the residents' rooms, the residents in the facility did not have difficulty going in and out of their rooms. Each resident in the affected room had beds and side drawers and were satisfied with the room size. There was adequate room for the operation and use of wheelchairs and walkers. The nursing staff had full access to provide treatment, administer medications, and assist residents.

During the Resident Council meeting on 2/19/2025 at 2 p.m., there were no concerns brought up regarding room size.

During an interview with the administrator (ADM) on 2/19/2024 at 3:15 p.m., the ADM stated some of the rooms are smaller than required but no residents have complained about the room size and the staff were able to provide adequate care to the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 055408