Bel Vista Healthcare Center

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

condition.During a telephone interview on 9/12/2025 at 1:51 p.m. with Resident 1, Resident 1 stated the Board and Care where he was discharged looked unsafe and the facility personnel looked suspicious.

During a telephone interview on 9/16/2025, at 11:59 a.m. with the Director of Patient Care (DOPC- third party collaborating with facility's social worker to find a place for a resident who is going to get discharged ),

the DOPC stated the facility where the resident was discharged was not a Board and Care. The DOPC stated it was a recuperative care facility which was transitional housing for homeless people, and people who came from jail. The DPOC stated residents should be independent and should not require medical services. The DOPC stated they received an online referral from the facility's social worker and had spoken to Resident 1 over the phone about the place. The DOPC stated Resident 1 agreed but she did not know if

the resident knew the facility was not a board and care. The DOPC stated Resident 1 refused to stay as soon as he got to the facility because of his fear of gangs and the facility's location. The DOPC stated Resident 1 left the recuperative care facility on his own and went back to an undisclosed place at Long Beach.During a concurrent interview and record review on 9/15/2025, at 2:34 p.m. with Case Manager (CM) 1 of Resident 1's electronic medical, CM 1 stated Resident 1 was discharged to a board and care on 8/28/2025. CM 1 stated the Social Worker (SW) arranged for the board and care facility.During an interview

on 9/16/2025, at 10:32 p.m. with CM1, CM 1 stated Resident 1 was discharged to a Recuperative Care Facility and not to a Board and Care. CM1 stated Recuperative Care Facility is a home for homeless people and not a licensed facility. CM1 stated a Board and Care are for residents that need more help with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and help residents with their medications. CM 1 stated the facility should have screened the facility to ensure the place was safe and able to meet the needs of Resident 1.During an interview on 9/16/2025, at 11:17 a.m. with the Administrator (ADM), the ADM stated there was

a miscommunication between the SW and the DPOC about Resident 1's discharge. The ADM stated he was disappointed about what happened to Resident 1 getting discharged to a Recuperative Care facility instead of Board and Care. The ADM stated it was the responsibility of the facility to screen the place where Resident 1 will be discharged to ensure safe discharge.During a concurrent interview and record review on 9/16/2025, at 2:58 p.m. with the Director of Nursing (DON), Resident 1's electronic medical record was reviewed. The DON stated the physician ‘s order indicated to discharge Resident 1 to a Board and Care, obtain Home Health for physical and occupational therapy for safety and Registered Nurse for medication compliance. The DON stated the SW was on vacation and did not know what happened to the discharge of Resident 1. The DON stated the facility should have followed the physicians' discharge order to a Board and Care. The DON stated the SW should have verified the placement and discussed with Resident 1 and

the physician if the resident was going to a recuperative care facility instead of board and care. The DON stated Resident 1 being discharged to Recuperative Care instead of a Board and Care could have caused emotional distress and could result in an inappropriate discharge.During a review of facility's policy and procedure (P&P) titled, Transfer or Discharge, revised 3/2025, the P&P indicated discharges must meet specific criteria and require resident or representative notification, orientation and documentation in the medical record.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bel Vista Healthcare Center

5001 East Anaheim Street Long Beach, CA 90804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to provide the proper notice for discharge for one of two sample residents (Resident 1) by failing to:1. Provide a written discharge notice (30-day notice of proposed discharge) at least 30 days prior to the transfer or discharge of the resident from the facility.This failure had

the potential to put Resident 1 at risk for inappropriate and unsafe discharge.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses including hypertension (HTN-high blood Pressure), glaucoma( eye condition that damages the optic nerve which can lead to vision loss or blindness), lack of coordination and protein-calorie malnutrition( condition that occurs when a person does not consume enough protein and calories to meet body's needs).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/28/2025, the MDS indicated the resident had an intact cognition (thought process) and required supervision or touching assistance ( helper provides verbal cues as resident completes the activity) with bathing, dressing, transferring to and from a bed to a chair , toilet transfer ( ability to on and off a toilet or commode) bed mobility.During a review of Resident 1's Order Summary Report dated 8/27/2025, the Order Summary Report indicated to discharge the resident to Board and Care on 8/28/2025. During a review of Resident 1's Notice of Proposed Transfer/Discharge (formal, written notification from long term care facility to a resident and their representative about a planned move from the facility and must be provided at least 30 days in advance under federal law) dated 8/28/2025, the Notice of Proposed Transfer/ Discharge indicated the resident received and signed the form on 8/28/2025. The Notice of Proposed Transfer indicated the resident was discharged to a Board and Care (a small residential care setting providing housing, meals, and personal care assistance for adults and seniors who cannot live alone but do not require skilled nursing care) on 8/28/2025.During a review of Resident 1's Progress Notes dated 8/28/2025 at 10:01 a.m., the Progress Notes indicated the resident was discharged to a board and care in stable condition.During a concurrent interview and record review on 9/15/2025, at 3:06 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's Notice of Proposed Transfer/ Discharge was reviewed. LVN 2 stated

the Notice of Proposed Transfer/Discharge was provided to Resident 1 on the day of discharge. LVN2 stated the Notice of Proposed Transfer/ Discharge is provided to residents upon their discharge.During an

interview on 9/16/2025, at 2:58 p.m. with the Director of Nursing (DON), the DON stated the facility provides a Notice of Proposed Transfer /Discharge to the residents on the day that they are leaving the facility or the day they get discharged . The DON stated she was not aware the written notice for discharge should be provided to the residents at least 30 days before the discharge as indicated in the facility policy.

The DON agreed that the Notice of Proposed Transfer/ Discharge should be given at least 30 days prior to

the discharge of the residents to give ample time to decide and be informed about their discharge.During a

review of facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, revised 3/2025, the P&P indicated residents or resident representative are notified of an impending discharge at least 30 days prior to transfer or discharge. The P&P indicated the written notice should be in a language or manner that the residents can understand.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bel Vista Healthcare Center

5001 East Anaheim Street Long Beach, CA 90804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 2's constipation. LVN 1 stated Resident 2 did not receive any medication for constipation, and she should have administered the prn laxatives to relieve constipation. LVN 1 stated if all the prn laxatives are ineffective, the physician will be notified because the resident could be at risk for fecal impaction. During a concurrent interview and record review on 9/16/2025, at 10:49 a.m. with the Director of Staff Development (DSD), Resident 2's MAR was reviewed. The DSD stated CNAs report to the charge nurse when a resident has no bowel movement and if a resident has no bowel movement for two days, the licensed nurse should administer medications for constipation. The DSD stated the staff should have monitored the frequency of Resident 2's bowel movement on the MAR and the CNAs should have notified the licensed nurse about Resident 2's constipation.During an interview on 9/16/2025, at 3:54 p.m. with the Director of Nursing (DON), the DON stated the charge nurse should have checked to see if Resident 2 had a bowel movement, administer the laxatives if needed and notified the physician if the prn laxatives were ineffective. The DON stated Resident 2 could have developed abdominal pain, nausea, vomiting and constipation if the resident was not monitored and prn laxatives not administered as ordered by the physician for constipation.During a

review of facility's Job Description for Certified Nursing Assistant, the Job Description of Certified Nursing Assistant indicated the CNA will report all changes in the resident's condition to the Nurse Supervisor/ Charge Nurse as soon as practical and performed all assigned tasks as instructed by the supervisor and in accordance with facility's policies and procedures.During a review of the facility's Job Description of LVN,

the Job Description of LVN indicated the LVN will review the resident's charts for specific medication orders as necessary and will make periodic checks to evaluate resident's physical and emotional condition.

Event ID:

Facility ID:

If continuation sheet