Cerritos Vista Healthcare Center

F-F760)

Findings:

a.During a review of Resident 114's Admission record, the Admission Record indicated Resident 114 was admitted to the facility on [DATE REDACTED] with diagnoses including cholangitis (inflammation of the bile ducts [tube that releases digestive secretions), muscle weakness, and pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region.

During a review of Resident 114's History and Physical (H&P), dated 6/17/2024, the H&P indicated Resident 114 had the capacity to understand and make decisions.

During a review of Resident 114's Minimum Data Set (MDS - a resident assessment tool), dated 12/23/2024,

the MDS indicated Resident 114's cognition (ability to learn reason, remember, understand, and make decisions) was intact, required setup or clean-up assistance for eating, required moderate assistance (helper did less than half the effort) for eating, and dependent (helper does all of the effort) for toileting and bathing.

During a review of Resident 114's order summary report, Resident 114 did not have a physician order to self-administer TUMS or an antacid.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0761 During a concurrent observation and interview on 3/17/2025 at 11:23 a.m., with Resident 114, Resident 114 had a bottle of TUMS at bedside. Resident 114 stated the staff (unidentified) told her (Resident 114) to put Level of Harm - Minimal harm or her antacid medication away because the state surveyors were in the facility. Resident 114 stated she took potential for actual harm the TUMS a few times and the staff (unidentified) are aware that the bottle of TUMS is at bedside.

Residents Affected - Few During a concurrent observation and interview on 3/17/2025 at 3:23 p.m., with licensed vocational nurse (LVN) 1, Resident 114 was observed to have the TUMS at bedside. LVN 1 stated TUMS should not be at the bedside and needed a physician order to be administered to the resident.

During a concurrent interview and record review on 3/20/2025 at 2:45 p.m. with the registered nurse supervisor (RNS) 1, Resident 114's Self Administration of Drugs Assessment, dated 6/17/2025, was reviewed. RNS 1 stated the assessment indicated Resident 114 was unable to state the appropriate situation for self-administration of PRN (given as needed or requested) medications and required assistance to correctly read labels and/or identify each medication, correctly state what each medication is for, correctly state the time/frequency medications are to be taken, and correctly state the correct dosage/quantity for each administration. RNS 1 stated only authorized facility staff should have access to all residents' medications. RNS 1 stated when residents can self-administer medications stored at the bedside it places the resident at risk for medication interactions, missed symptoms that the resident is self-treating, abusing the medication, and possible overdose.

During a review of the facility's policy and procedure (P&P), titled Self-Administration of Medications, revised February 2021, the P&P indicated if the team determines a resident cannot safely self-administer medications, the nursing staff administers the resident's medications any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

b. During a review of Resident 71's Admission Record (a document containing diagnostic and demographic information), the Admission Record indicated Resident 71 was admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) with Acute (sudden onset) upper and Lower Respiratory Infection (an infection that may interfere with normal breathing) and Asthma.

During a review of Resident 71's MDS dated [DATE REDACTED], the MDS indicated for Resident 71's there was no behavior present for inattention, disorganized thinking, and no altered level of consciousness. Resident 71's MDS indicated the resident was independent for eating and was dependent, requiring the assistance of two or more staff for oral hygiene, toileting, bathing, dressing, and personal hygiene.

During a review of Resident 71's Order Summary Report, the Order Summary Report indicated Resident 71's orders included an order for Fluticasone and Salmeterol 250 mcg/50 mcg, instructions indicated to inhale 1 (one) puff orally (by mouth) every 12 hours for COPD. Rinse mouth after use, order dated 2/14/25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0761 During a concurrent observation and interview on 3/19/25, at 12:25 PM at MedCart 4A with Licensed Vocational Nurse (LVN) 1, one inhaler of fluticasone and salmeterol 250 mcg/50 mcg was found with an Level of Harm - Minimal harm or open date of 2/15/25, labeled for Resident 71. LVN 1 stated she administered a dose of fluticasone and potential for actual harm salmeterol 250 mcg/50 mcg inhaler to Resident 71 this morning (3/19/25). LVN 1 stated Resident 71's fluticasone and salmeterol 250 mcg/50 mcg inhaler was opened on 2/15/25 and expired on 3/17/25 and Residents Affected - Few should have been removed and not administered to the resident after 3/17/25.

During an interview on 3/19/25 at 1:02 PM with RNS 1, RNS 1 stated, fluticasone and salmeterol 250 mcg/50 mcg inhaler expires after 30 days and should not remain inside of the medication cart, because a licensed nurse may administer the medication to a resident without checking the expiration date. RNS 1 stated administering an expired medication may reduce the efficacy, potency, and quality of the medication and the resident may not respond well to the treatment and cause the resident to need the medication sooner than prescribe and lead to medication errors.

During a concurrent interview, record review, and review of the manufacturer's label on 3/19/25, at 1:09 PM with RNS 1, RNS 1 reviewed the manufacturer's labeling for Resident 71's fluticasone and salmeterol 250 mcg/50 mcg inhaler, the manufacturer's label indicated, Discard the inhaler 1 (one) month after opening the foil pouch or when the counter reads '0' (zero, after all blisters have been used), whichever comes first. Resident 71's electronic Medication Administration Record (eMAR, a digital system used in healthcare to track and document medication administration) was reviewed for the month of 3/2025. RNS 1 stated three different license nurses administered expired fluticasone and salmeterol 250 mcg/50mcg inhaler to Resident 71 on:

3/19/25 at 9:38 am scheduled for 9 am administration initialed by LVN 4

3/18/25 at 20:45 pm scheduled for 9 pm administration initialed by LVN 5

3/18/25 at 8:22 am, scheduled for 9 am administration initialed by LVN 1

During an interview on 3/19/25 at 1:48 PM, with the Director of Nursing (DON) inside of the DON's office, DON stated the purpose of putting an open date on Resident 71's fluticasone and salmeterol 250 mcg/50 mcg inhaler was to ensure a replacement inhaler was ordered and received from the pharmacy before the current medication expires.

During a review of the facility's policy and procedures titled, Administering Medications, dated 3/23, indicated, The expiration/beyond use date on the medication label is checked prior to administering.

During a review of the facility's policy and procedures titled, Medication Labeling and Storage, dated 2/23, indicated The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated ore deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

50144

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46537 potential for actual harm Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure Residents Affected - Few (P&P) titled, Dental services, revised 12/2016, which indicated routine and emergency dental services were available to meet residents' oral health services in accordance with the resident's assessment and plan of care by not replacing missing dentures and following up after a dental visit for one of three sampled residents (Resident 66).

This deficient practice had the potential to result in Resident 66 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem.

Findings:

During a review of Resident 66's Admission Record, the Admission Record indicated, Resident 66 was initially admitted to the facility on [DATE REDACTED] and last re-admission was on 10/11/2024 with diagnoses including dysphagia (difficulty swallowing), cerebral infarction (loss of blood flow to a part of the brain) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).

During a review of Resident 66's History and Physical (H&P), dated 10/12/2024, the H&P indicated, Resident 66 had the capacity (ability) to understand and make decision.

During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 1/29/2025,

the MDS indicated Resident 66 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, oral hygiene, bed mobility, chair/bed to chair transfer, dressing, and supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistant as resident completes activity) for eating. The MDS indicated, Resident 66 had no natural teeth or tooth fragments (edentulous).

During a review of Resident 66's Order Listing Report (OLR), dated 3/19/2025, the OLR indicated, provide dental consult and treatment as needed for dental problems was ordered on 10/11/2024.

During a review of Resident 66's Social Service Notes (SSN), dated from 2/4/2025 to 3/18/2025, the SSN indicated, there was no follow up notes regarding Resident 66's denture.

During a review of Resident 66's untitled Care Plan (CP) revised 3/22/2024, the CP Focus indicated, alteration in nutritional status related to edentulous (no natural teeth). The CP Goal indicated, minimize any unplanned weight changes daily. The CP Interventions indicated, observe for chewing or swallowing difficulties and dental consult if needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0790 During a concurrent observation and interview on 3/17/2025, at 2:59 p.m., with Resident 66 in her room, Resident 66 did not have natural teeth. There were no dentures noted at the bedside. Resident 66 stated, Level of Harm - Minimal harm or she did not know where her dentures were. Resident 66 stated, the first set of dentures she got did not fit potential for actual harm properly and the second set of dentures were missing. Resident 66 stated, she requested new dentures to

the Social Service Director (SSD), but no one had updated her on the status of her replacement dentures. Residents Affected - Few Resident 66 stated, she had discomfort while she was trying to eat or chew foods due to missing teeth. Resident 66 stated, she felt embarrassed when she was talked to other people because she had no teeth.

During a concurrent interview and record review on 3/19/2025, at 2:57 p.m., with the SSD, Resident 66's Dental Notes, dated 3/7/2025 were reviewed. The Dental Notes indicated, Resident 66 lost her dentures a few months ago, but Resident 66 said she did not want new ones. The Dental Notes indicated, Resident 66 was unable to receive treatment. The SSD stated, she did not know why Resident 66 declined a new set of dentures and she did not follow up with Resident 66 to find out the reason of refusal. The SSD stated, she should have followed up with Resident 66 and found out the reason she refused the dentures because providing the dentures to Resident 66 was important to prevent weight loss.

During an interview on 3/20/2025, at 3:51 p.m., with the Director of Nursing (DON), the DON stated, providing dentures to Resident 66 in a timely manner was important because it could negatively affect the ability to eat, and it could lead to social isolation. The DON stated, the SSD should have followed up with Resident 66 after Resident 66's dental visit of 3/7/2025 because she might be able to help the resident.

During a review of the facility's Policy and Procedure (P&P) titled, Dental services, revised 12/2016, the P&P indicated, Policy Statement: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: 6. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible . 10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. 11. All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred.

During a review of the facility's Policy and Procedure (P&P) titled, Job Description: Social Services Designee, dated 3/12/2014, the P&P indicated, Essential Duties: o Assists in the provision of the medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident o Facilitates any identified problems, e.g., dental visual, communication, etc. Assists with supplying a communication board or whatever tools necessary to ensure communication to make resident needs known. o Creates, reviews and updates care plan and progress notes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46537

Residents Affected - Some Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 114 out of 130 total residents in the facility by not:

A. Ensuring food Items were dated, labeled, and sealed properly.

B. Ensuring the temperature of ground beef patties in the steam tray were above 155 Fahrenheit (F) per facility's Policy and Procedure (P&P) titled, Meal Service, undated, which indicated, food temperature would be taken to ensure ground meat or ham was at least 155 degrees Fahrenheit, during the trayline (Resident's trays are assembled and checked for accuracy before food is delivered to them).

C. Ensuring Dietary Aid (DA) 1 performed hand hygiene (washing hands) and changed gloves between tasks

during trayline.

These failures had the potential to result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization .

Findings:

A. During a concurrent observation and interview on [DATE REDACTED], at 8:20 a.m., with Dietary Supervisor (DS), in

the dry storage area, there were food items that were not dated as follows:

a. Opened and used seasoned breadcrumbs in a plastic bin with no Receiving Date (RD- the day of delivery), Open Date (OD) of [DATE REDACTED], and no Use By (UB).

b. Opened and used dry grits in a pack that was not sealed, and the side portion was open to air with RD of [DATE REDACTED], OD of [DATE REDACTED], and no UD

c. Opened and used dry green split peas in a plastic container with no RD, OD of[DATE REDACTED] and no UB.

d. Opened and used dry barley in a plastic container with no RD, OD of[DATE REDACTED] and no UB.

e. Opened and used small white beans in a plastic container with no RD, OD of[DATE REDACTED] and no UB.

f. Opened and used Sliced Rye bread in a plastic bag with RD of [DATE REDACTED], OD of [DATE REDACTED] and no UB.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0812 The DS stated, all food items should have been labeled with receiving date when the facility got delivery from vendors. The DS stated, all food items should have open date and used by date (expiration date). The DS Level of Harm - Minimal harm or stated, it was all dietary staff (including herself) responsibility to check all food items for labels, dates, potential for actual harm properly stored and sealed. The DS stated these practices were important to make sure all food items were

in good condition because the residents consumed these food items. The DS stated, all opened food items Residents Affected - Some should be closed tightly to prevent contamination (the unwanted pollution of something by another substance). The DS stated, once the food items were opened, each food item has a different shelf life (a time limit on how long a product can be stored before it becomes unsuitable for consumption or use). The DS stated, all staff should refer to the Dry Goods Storage Guidelines for shelf life after opening and label UB date on food items.

During a concurrent observation and interview on [DATE REDACTED], at 8:39 a.m., with the DS, in the walk- in refrigerator, there were food items that were not dated, labeled, and properly sealed, as follows:

a. Prepared chicken salad in plastic container with preparation date of [DATE REDACTED] with no UB

b. Opened and used butter milk ranch dressing in a plastic container (dressing was dripping from the cap to outer side of the container) with no RD, OD of [DATE REDACTED], and no UB

c. Opened and used mustard in a plastic container with no RD, OD of [DATE REDACTED], and no UB.

d. Opened and used sour cream in a plastic container with RD of [DATE REDACTED], OD [DATE REDACTED], and UB.

e. Opened and used sliced American Cheese (no label) with RD of [DATE REDACTED], OD [DATE REDACTED], and no UB.

f. Prepared fruit plate in small plate (no label) with preparation date of [DATE REDACTED] with no UB.

The DS stated, all food items should be dated, and dietary staff should follow the Refrigerator and Freezer Storage Chart to ensure safety of perishable items that required refrigeration.

The DS stated, all pre-made or prepared food items should have the labels and UB.

During a concurrent observation and interview on [DATE REDACTED], at 8:44 a.m., with [NAME] (CK) 1, dry seasoning shelf near the sink, there were food items that were not dated and properly sealed, as follows:

a. Opened and used Paprika powder in a plastic container (lid was opened) with RD of [DATE REDACTED], OD of [DATE REDACTED], and no UB.

b. Opened and used Onion powder in a plastic container (lid was opened) with RD of [DATE REDACTED], OD of [DATE REDACTED], and no UB.

CK 1 stated, all lids should be closed tightly, and all food items should have UB.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0812 During a review of the facility's Policy and Procedure (P&P) titled, Storage of Canned and Dry Goods, revised 2019, the P&P indicated, Policy: Food and supplies will be stored properly and in a safe manner. Level of Harm - Minimal harm or Procedures .7. Food items will be dated and labeled when placed in the containers .9. Remove food from potential for actual harm packaging boxes upon delivery to minimize pests. Loose items should be placed in containers or bins. Bins will be dated, labeled, and covered . 13. All food products will be used according to the specified Food Residents Affected - Some Storage Guidelines.

During a review of the facility's Policy and Procedure (P&P) titled, Procedure for Refrigerated Storage, revised 2019, the P&P indicated, Procedures: 6. Leftover food or unused portions of packaged foods should be covered, dated, and labeled to ensure they will be used first .11. All items should be properly covered, dated, and labeled. Food items should have the following appropriate dates: Delivery date -upon receipt, Open date-opened containers of Potentially Hazardous Foods (PHF), Thaw date-any frozen items.

During a review of the facility's Policy and Procedure (P&P) titled, Dating and Labeling, undated, the P&P indicated, Policy: To ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas. Procedure: 4. All items should be properly covered, dated, and labeled .6. No food item that is expired or beyond the best buy date are in stock.

During a review of the facility's Policy and Procedure (P&P) titled, Labeling: Food in Refrigerator, undated,

the P&P indicated, Policy: Food that is cooked or open and placed into refrigerator will be labeled with name of food item and date placed in refrigerator. Procedure: 1. Items in refrigerator will be properly covered, dated, and labeled .3. Food items will be removed and discarded after 72 hours of placement in refrigerator.

B. During a concurrent observation and interview on [DATE REDACTED], at 12:03 p.m., with CK 1, in the kitchen during

the trayline for lunch, CK 1 was checking the temperature of food items in steam trays. CK 1 checked the temperature of the ground beef patties and the thermometer (an equipment to check the temperature) indicated, the temperature reading was 138F. CK 1 stated, she did not know why the temperature dropped dramatically, because it was above 190F when she checked the temperature at 11:55 a.m.

During an interview on [DATE REDACTED], at 12:13 p.m., with the DS stated, the DS stated meat temperature should be above 165F for safety, because if the food items were not reached certain levels of temperature, food might be spoiled and make the residents sick.

During a review of the facility's Policy and Procedure (P&P) titled, Meal Service, undated, the P&P indicated, Procedure: Food temperature will be taken to ensure all hot foods are at a proper serving temperature. Food temperature will be recorded daily. Food item: ground meat or ham - at least 155 degrees Fahrenheits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 0812 C. During a concurrent observation and interview on [DATE REDACTED], at 12:23 p.m., with Dietary Aid (DA) 1 in the kitchen, DA 1 touched a juice cup with bare hands and then put gloves on without washing hands. DA 1 Level of Harm - Minimal harm or pushed the lunch cart toward the door after putting the gloves on. DA 1 started touching the clean lids for the potential for actual harm plates without washing hands or changing gloves after touching the cart. DA 1 stated, she should have performed hand hygiene and changed her gloves between the tasks to prevent cross contamination (the Residents Affected - Some physical movement or transfer of harmful bacteria from one person, object or place to another).

During an interview on [DATE REDACTED], at 3:51 p.m., with Director of Nursing (DON) , the DON stated, all staff should perform hand hygiene between tasks to prevent cross contamination and protect vulnerable residents from infections.

During a review of the facility's Policy and Procedure (P&P) titled, Hand Washing, undated, the P&P indicated, Hand washing: 2. After handling carts, soiled dishes and utensils .Use of Disposable Gloves: 1. Disposable gloves will be worn when handling food directly with bare hands to prevent food borne illnesses. 2. Disposable gloves are a single use item and should be discarded after each use. 3. Hands are to be washed before putting on disposable gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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** 46537 potential for actual harm 49573 Residents Affected - Some Based on observation. interview and record review, the facility failed to implement infection control measures by failing to:

A. Ensure padded side rails (a padded side fitted to a bed for safety) that were wrapped with foam (a soft, porous material, and the degree of porosity can vary depending on the type of foam) and paper tape were disinfected (the process of cleaning something, especially with a chemical, to destroy bacteria) properly for one of three sampled residents (Resident 70).

B. Ensure Treatment Nurse (TN)1 performed hand hygiene while she was checking lunch trays in dining room.

C. Implement the facility's policies and procedures (P&P) titled Handwashing/Hand Hygiene, revised in April 2023 which indicated, all personnel shall follow the handwashing/hand hygiene procedures to help prevent

the spread of infections to other personnel, residents, and visitors before and after direct contact with residents; .before preparing or handling medications, when Licensed Vocational Nurse (LVN 1), did not perform hand hygiene after medication preparation and prior to administration for one of one resident (Resident 334).

These failures had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors.

Findings:

A. During a review of Resident 70's Admission Record, the Admission Record indicated, Resident 70 was admitted to the facility on [DATE REDACTED] with diagnoses including seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), liver transplant (the replacement of a diseased liver with the healthy liver from another person), and peritonitis (a redness and swelling [inflammation] of the lining of the belly or abdomen).

During a review of Resident 70's History and Physical (H&P), dated 3/13/2025, the H&P indicated, Resident 70 had no capacity (ability) to understand and make decisions.

During a review of Resident 70's Minimum Data Set (MDS - a resident assessment tool), dated 1/7/2025, the MDS indicated Resident 70 was dependent and required assistance (Helper does all of the effort) from two or more staff for toilet hygiene, shower/bathe, dressing, personal hygiene, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, and chair/bed to chair transfer.

During a review of Resident 70's Order Listing Report (OLR), dated 3/19/2025, the OLR indicated, place bilateral upper half side rails up with floor mat to decrease potential injury was ordered on 12/3/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 Resident 70's Care Plan (CP), revised on 1/18/2023, the CP Focus indicated, Resident 70 had seizure disorder and at risk for injury. The CP Goal indicated, Resident 70 will have no injury. The CP Level of Harm - Minimal harm or Interventions indicated, provide padded siderails if indicated. potential for actual harm

During a review of Resident 70's Care Plan (CP), revised on 1/21/2023, the CP Focus indicated, Resident 70 Residents Affected - Some was at high risk for infection. The CP Goal indicated, reduce risk for active infection. The CP Interventions indicated, cleaning and disinfection of equipment and high touch surface areas.

During an observation on 3/17/2025, at 2:26 p.m., in Resident 70's room, Resident 70's siderails were wrapped with foam and paper tape.

During a concurrent observation and interview on 3/19/2025, at 10:49 a.m., in Resident 70's room, with the Maintenance Supervisor (MS), of Resident 70's siderails, the siderails were wrapped with foams and paper tapes and the left side of the paper tape was peeling off and hanging loose. The MS stated the foam was placed to prevent Resident 70 from head injuries due to seizures. The MS stated, housekeepers cleaned the foam with a bleach germicidal (a substance that containing a substance that kills germs) wipes. The MS stated, he did not realize that the label indicated, it was for nonporous (does not allow liquid or air to pass through it) and hard surfaces. The MS stated, the bleach germicidal wipes were not the appropriate cleaning agents to clean foam and paper tape. The MS stated, if the foam and paper tapes were not cleaned with a proper sanitizing (the process of removing germs either by cleaning or by disinfecting surfaces) solution, it would cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and spreading infection because it would not kill bacteria effectively.

During an interview on 3/19/2025, at 4 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated, that

the manufacturer's instructions on the products indicated they were to be used on hard, nonporous surfaces.

The IPN stated that the foam and paper tape wrapped on the bedrails were not appropriate because they were porous and could cause the surface to not be cleaned properly, and the sanitizing agent could also break down the foam and tape. The IPN stated, this practice would place vulnerable residents at risk for infection.

During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 4/2023, the P&P indicated, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. (2) Non-critical environmental surfaces include bed rails, bedside tables, etc. (3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturer's instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g. , use-dilution, shelf life, storage, material compatibility, safe use and disposal).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 B. During a concurrent observation and interview with Treatment Nurse (TN) 1, in the dining room during dining observation, TN 1 was checking the resident's lunch trays. TN 1 touched the resident's tray and lifted Level of Harm - Minimal harm or the lid. After lifting the lid, TN 1 did not wash her hands, and she touched a diet listing document and flipped potential for actual harm the pages. After confirming the diet order, TN 1 touched the next tray and lifted the lid without performing hand hygiene. While TN 1 was checking the resident's tray, TN 1 pulled down her mask then she touched Residents Affected - Some the door of the lunch cart. Without washing her hands or changing gloves, TN 1 touched another resident's tray. TN 1 stated, she should have washed her hands between tasks, and she should have performed hand hygiene when she touched her mask before checking the tray to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another).

During an interview on 3/19/2025, at 4 p.m., with the IPN, the IPN stated, hand hygiene should be performed between tasks and after touching high touch surfaces (those that people frequently touch with their hands, which could therefore become easily contaminated with microorganisms and picked up by others on their hands). The IPN stated, the staff should have sanitized the hands when touching the trays after touching her mask and the door of the lunch cart.

During an interview on 3/20/2025, at 3:51 p.m. with the Director of Nursing (DON), the DON stated, all staff should perform hand hygiene before, after, and between the tasks. The DON stated hand hygiene was the first line of defense against infection. DON stated, touching the surfaces could cause cross contamination and staff should have performed hand hygiene to protect the residents and themselves.

During a review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene, reviewed 10/2023, the P&P indicated, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene. 1.All personnel are trained and regularly in-serviced on

the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene: 1. Hand hygiene is indicated: c. after contact with blood, body fluids, or contaminated surfaces. e. after touching the resident's environment.

C. During a review of Resident 334's Admission Record, the Admission Record (crucial document that details

a resident's initial health status, and other pertinent information upon admission) indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (a condition where blood flows to the brain is interrupted), and malignant neoplasm of prostate (Prostate cancer).

During a review of Resident 334's MDS dated [DATE REDACTED], the MDS indicated Resident 334's cognitive skills for daily decision making were moderately impaired.

During a medication administration observation on 3/18/2025 at 8:37 a.m., with LVN 1, LVN 1 was observed preparing a total of five oral medications for Resident 334.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 056405 Department of Health & Human Services Printed: 09/04/2025 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 056405 B. Wing 03/20/2025

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

Cerritos Vista Healthcare Center 17836 Woodruff Avenue 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 medication administration observation on 3/18/2025 at 8:50 a.m.; with LVN 1, LVN 1 was observed entering Resident 334's room to administer the five oral medications prepared without performing hand Level of Harm - Minimal harm or washing or sanitizing hands. LVN 1 was observed using her hands to hold the straw in order for Resident potential for actual harm 334 to drink water.

Residents Affected - Some During an interview on 3/19/2025 at 8:21 a.m., with LVN 1, LVN 1 stated she did not wash or sanitize hands

after preparing the medications for Resident 334. LVN 1 stated she held the straw for Resident 334 in order for the resident to drink the water to take medication. LVN 1 further stated not washing or sanitizing own hands could lead to the spread of infection.

During a review of the facility's policies and procedures (P&P) titled Handwashing/Hand Hygiene, revised in April 2023, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents; .Before preparing or handling medications.

During a review of the facility's policies and procedures (P&P titled, Administering Medications, revised in March 2023, the P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

50594

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 056405