Bay Vista Healthcare & Wellness Centre, Lp

F-F812

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 056042

F-F908

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 45028 potential for actual harm Based on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a Residents Affected - Some group of facility staff who identifies, evaluates, and implements measures to improve the quality of care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure continued oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey (7/19/2021).

This deficient practice resulted in the facility having repeat deficiencies in quality of care, such as pharmaceutical services (procuring, dispensing, distributing, storing, and administering of medications), medication error rate of five percent or more, infection control, and physical environment.

Findings:

During a review of the facility's Statement of Deficiencies for the 2021 Recertification Survey, the Statement of Deficiencies indicated the following repeat deficiencies were identified: quality of care, pharmaceutical services, medication error rate of five percent or more, infection control, and physical environment.

During a review of the facility's current QAPI plan updated 11/10/2023 and revised 5/28/2024, indicated there was an ongoing QAPI for fall management.

During a review of the facility's current QAPI plan initiated 6/1/2024, indicated there was an ongoing QAPI for behavior management.

During an interview on 6/30/2024 at 6:04 p.m., with the Director of Nursing (DON), the DON stated the identified deficient practices in medication administration errors and infection control practices would be addressed immediately.

During an interview on 6/30/2024 at 6:49 p.m., with the Administrator (ADM) the ADM stated key measures, risks and action plans are discussed during the QAPI meetings. The ADM stated current ongoing QAPI's include fall management, behavior management and a previous deficiency regarding abuse. The ADM stated

the facility did not have a focus QAPI prior to the finding of the issues with the facility's freezers which were identified again during the recertification survey nor a system in place to ensure the freezers were functioning correctly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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 0865 During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance (QAPI) Program, revised 3/28/2024, indicated the facility implements and maintains an ongoing, facility-wide Level of Harm - Minimal harm or Quality Assurance and Performance Improvement (QAPI) Program designed to monitor and evaluate the potential for actual harm quality of resident care, pursue methods to improve quality of care, and resolve identified issues. The P&P indicated the purpose of the QAPI program is to implement a process that identifies opportunities for Residents Affected - Some improvement and leads to optimal achievement in clinical and operational outcomes, and overall quality of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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** 43906 potential for actual harm Based on observation, interview, and record review the facility failed to ensure infection control practices was Residents Affected - Many implemented. The facility failed to:

1. Ensure personal protective equipment (PPE- equipment used to prevent or minimize exposure to hazards) was easily accessible for direct patient care staff on residents with Enhanced Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, and indwelling devices).

These deficient practices had the potential for the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility.

2. Ensure the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) indicated testing protocols (deliberate action to see if something works) for control measures (actions taken to reduce the potential of exposure to the hazard) and documented results of testing completed.

This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) and water borne infections.

Findings:

1.During an initial tour to the facility on [DATE REDACTED] at 7:26 a.m., observed Certified Nursing Assistant (CNA) 1 walking in the hallway with gloves on. CNA 1 entered a resident room with EBP signage on the door.

During a review of Resident 41's Admission Record, the Admission Record indicated Resident 41 was admitted to the facility on [DATE REDACTED] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), pressure ulcer (an injury that breaks down the skin and underlying tissue) of left buttocks unstageable, pressure ulcer of sacral region, unstageable.

During a review of Resident 41's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/5/2024, indicated Resident 41's has clear speech and can understand others and can be understand by others.

During a concurrent observation and interview on 6/29/2024 at 8:10 a.m., with CNA1, CNA 1 stated Resident 41 had pressure ulcer at the buttocks area, so she was only allowed to be up in the wheelchair for two (2) hours and goes back to bed to relieve the pressure from her back. CNA 1 stated she will be providing morning care to Resident 41 and there was no PPE cart close by to get the gloves or gowns needed to provide care for Resident 41, so she needs to walk from where the PPE cart was located and then she puts

the gloves and carry the gown until she goes to resident room and don (put on) the gown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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 6/29/2024 at 1:39 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that CNAs should not be walking around with gloves on because of infection control. LVN 3 stated that Infection Level of Harm - Minimal harm or Preventionist (IP) reminds every staff about infection control. potential for actual harm

During an interview on 6/30/2024 at 8:30 a.m., with the IP, the IP stated that his main role was infection Residents Affected - Many control and prevention. The IP stated staff should not walk around the facility with gloves on or any PPE. The IP added that soiled linen should not be carried around the facility to drop off to laundry.

During a record review of the facility's policies and procedure (P &P) titled Enhanced Barrier Precautions dated 6/7/2024, the P & P indicated during high contact resident care activities dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting gloves and gown prior to the high contact care activity (change PPE before caring for another resident) face protection may also be needed if performing activity with risk of splash or spray. To facilitate compliance with EBP make PPE, including gowns and gloves, available immediately outside of the resident room. PPE stations may be positioned between adjacent rooms for convenience, gowns and gloves are to be donned before each high contact task not prior to entering the room.

2. During an interview on 6/29/2024 at 5:30 p.m., the Administrator (ADM) stated facility water quality has not been tested and was unable to provide documentation of testing.

During a review of the facility policy and procedure titled Water Management Plan, revised 5/25/2023, the P&P indicated there will be quarterly measurement of water quality throughout the system to ensure changes that may lead to legionella growth were

During a review of the Centers for Disease Control and Prevention Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, a Practical Guide to implementing industry standards, dated 6/24/2021, the guide indicated:

a. Water quality should be measured throughout the system to ensure that changes that may lead to legionella growth.

b. Document confirmatory procedures, including verification steps to show that the program was being followed as written and validation to show that the program is effective.

https://www.cdc.gov/control-legionella/php/toolkit/wmp-toolkit.html

44055

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 45537 potential for actual harm Based on observation, interview and record review, the facility failed to ensure three freezers and one Residents Affected - Many refrigerator in the facility's kitchen and food pantry were maintain in safe operating condition.

This failure had the resident food items stored in an unsafe condition that could potentially place the residents at risk for food-borne illnesses (illness cause by food contaminated with bacteria, viruses, parasites, or toxins).

Findings:

During an observation on 6/28/2024 at 3:24 p.m., at the facility's food pantry with the Dietary Supervisor (DS), the following were observed:

a. Freezer #1 that stored several bags of frozen tortilla have no thermometer to monitor the freezer's temperature. There was an opened bag of tortilla with no opened date tag and another tortilla bag unopened with ice crystals inside the bag.

b. Freezer #2 that stored packed bags of vegetables had a temperature of 2 (two) degrees Fahrenheit ( F a temperature scale) and there was an ice build up observed on the upper portion of the freezer.

c. Freezer #3 that stored sliced carrots and french fries had a temperature of 0 (zero) F and there was an ice buildup at the bottom of the freezer and clear liquid substance on the floor (outside of the freezer).

During an observation on 6/28/2024 at 5:02 p.m., at the facility's kitchen, the following were observed:

a. Freezer # 4 that stored frozen meat, ice cream, butter and popsicles had a temperature of one F and

b. Refrigerator #1 that stored milk and eggs had a temperature of 60 F.

During an observation on 6/29/2024 at 9:46 a.m. at the facility's food pantry with the Maintenance Director (MD), the following were observed:

a. Freezer #2 that stored packed bags of vegetables had a temperature of four F, and

b. Freezer #3 that stored sliced carrots and french fries had a temperature of 4 F and there was an ice buildup at the bottom of the freezer and clear liquid substance on the floor (outside of the freezer).

During a concurrent observation and interview on 6/29/2024 at 9:46 a.m. with the Maintenance Director (MD), the following were observed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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 0908 a. Refrigerator #1 that stored milk had a temperature of 38 F, there were no food items inside the refrigerator; and Level of Harm - Minimal harm or potential for actual harm b. Freezer #4 that stored frozen meat, ice cream, butter and popsicles had a letter D noted at the outside temperature monitor, meaning defrosting was taking place in the freezer, which was confirmed by MD as a Residents Affected - Many normal mechanism of the freezer to give the condenser coils to work.

During an observation on 6/29/2024 at 10:11 a.m., of the facility's kitchen with the Administrator, the following were observed:

a. Refrigerator #1 that stored milk had a temperature of 38 F and there were no food items inside the refrigerator; and

b. Freezer #4 that stored frozen meat, ice cream, butter and popsicles had a temperature of 1 F.

During an observation on 6/29/2024 at 12 p.m., of the facility's kitchen with the Administrator, Maintenance Supervisor and Dietary supervisor, the following was observed:

a.Freezer #4 that stored frozen meat, ice cream, butter and popsicles had an ice buildup on the upper section of the freezer with a temperature of 18.5 F as checked by the Maintenance Supervisor utilizing the facility's thermometer gun and the thermometer inside the freezer was 16 F.

During an observation on 6/29/2024 at 12:52 p.m., in the facility's kitchen with the Administrator, Maintenance Supervisor and Dietary supervisor, the following was observed:

a. Freezer #4 that stored frozen meat, ice cream, butter and popsicles had an ice buildup on the upper section of the freezer with a temperature of 5 F as checked by the Maintenance Supervisor utilizing the facility's thermometer gun and the thermometer inside the freezer was 4 F.

During an interview on 6/28/2023 at 5:20 p.m., the Dietary Supervisor (DS) stated the kitchen equipment such as the freezer and the refrigerator must be operating in proper temperatures (freezer must have a temperature of 0 [zero] and below F and refrigerator must operate with 40 F and below) to ensure the residents' food were stored safely, prevent the growth of bacteria that can cause food borne illnesses and

the quality of the food was maintained.

During an interview on 6/29/2024 at 9:46 a.m., the Maintenance Supervisor (MS) stated leakage and water condensation/ ice buildup inside the freezer signifies the equipment was not functioning properly and need to be replaced.

During an interview on 6/29/2024 at 10:11a.m., the Administrator stated she was not aware of the concerns of the kitchen and pantry cold storage equipment.

During an interview on 6/29/2024 at 5:06 p.m., the on call Registered Dietician stated the temperatures of the facilities cold storage equipment such as the freezer and refrigerator will have fluctuating temperatures depending on how often the kitchen staff were using them; however, the cold storage equipment must stay in

the proper temperature and a thermometer must be delegated in each of the equipment to ensure the equipment temperature was monitored and functioning safely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 056042 Department of Health & Human Services Printed: 09/22/2025 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 056042 B. Wing 06/30/2024

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

Bay Vista Healthcare & Wellness Centre, LP 5901 Downey Ave Long Beach, CA 90805

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 0908 During a review of the facility's freezer equipment manual titled Commercial Freezer Defrost Cycles Explained undated, the equipment manual indicated defrost cycles of the freezer avoid problems caused by Level of Harm - Minimal harm or the build up of ice and defrosting does not affect the interior temperature of the freezer cabinet and the food potential for actual harm held in the freezer.

Residents Affected - Many During a review of the facility's policy and procedure (P&P) on Equipment Operation revised 11/ 2014, the P&P indicated appropriate and safe equipment are being used in the facility.

During a review of the facility's P&P titled Food Storage and Handling revised 2/29/2024, the P&P indicated

the residents' food items must be stored at a safe and appropriate temperature in the freezer at a temperature of 0-degree (zero) Fahrenheit and below and in the refrigerator at a temperature of below 41 degrees Fahrenheit.

Cross Reference