Health inspection·June 18, 2021

F 0558 easy reach of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 2 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment and care screening tool) accurately reflect the resident's discharge destination for one of three sampled residents (Resident 79). Resident 79 who was discharged home was coded in the MDS assessment as discharged to acute hospital. Residents Affected - Few This deficient practice had the potential for the resident not to receive interventions to address specific care concerns. Findings: A review of Resident 79's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included status post (condition after) laminectomy (a type of surgery in which a surgeon removes part or all of the back bone) and spinal stenosis (a narrowing of the spinal canal). A review of Resident 79's Physician's Order dated 4/13/21 indicated may discharge (DC) home with home health. A review of Resident 79's Discharge Summary indicated the resident was discharged to home on 4/13/2021. A review of Resident 79's MDS dated [DATE] indicated acute hospital as discharge status. During a concurrent interview and record review on 6/17/21 at 10:31 a.m., the Minimum Data Set Coordinator 1 (MDS 1) stated Resident 79 was discharged to home on 4/13/2021. MDS 1 confirmed the discharge status was coded in the MDS assessment as discharged to acute hospital. During an interview on 6/17/21 at 11:01 a.m., the Director of Nursing (DON) stated accurate MDS assessment reflects how the facility address the resident's quality of care and concerns. A review of the facility's Policy and Procedure titled, Resident Assessment Instrument, revised September 2010, indicated the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 3 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to provide a communication board for one of 18 sampled residents (Resident 127) who primarily spoke a foreign language, as indicated in the comprehensive person-centered care plan. This deficient practice placed Resident 127 at risk of not being understood when communicating with staff, which can lead to a delay in meeting the resident's needs. Findings: A review of the admission Record indicated Resident 127 was admitted to the facility on [DATE] with diagnoses that included orthopedic (relating to correction of deformities of bones) aftercare, fracture (break in the bone) of right and left kneecaps, and history of falling. The admission Record indicated Resident 127's primary language was Spanish. A review of Resident 127's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/21/21, indicated the resident had clear speech, had the ability to understand others and be understood. The MDS indicated Resident 127 required extensive assistance with bed mobility, dressing, and toilet use. The MDS indicated Resident 127 required complete assistance with transferring positions and walking. During an observation in Resident 127's room on 6/15/2021 at 10:38 am, the resident was sitting on the side of the bed awake, alert, and oriented to person, place, and time. Resident 127's family member was at bedside and assisted in translation between English and Spanish. During an interview, Resident 127's family member stated the resident can understand a little bit of English, but primarily speaks Spanish. During an interview with the Director of Nursing (DON) on 6/15/2021 at 10:42 am, she stated there is no communication board in Resident 127's room at this time. DON stated the communication board should be hanging at the back of the wheelchair to be used to communicate effectively between staff and residents. A review of Resident 127's care plan dated 5/19/2021 indicated the resident has impaired communication pattern related to a language barrier. The care plan indicated Resident 127's native language was Spanish. The care plan goal indicated needs will be attended and met accordingly through next review dated 8/17/2021. The care plan interventions included providing a communication board as needed. A review of the facility's undated Policy and Procedure titled, Communication Barriers, Reduction of, indicated it is the policy of the facility to provide methods of communication to assure adequate communication between the resident and staff. The facility policy indicated they will make arrangements for interpreters or alternate means of communication, such as pictures, sign language, braille, etc., to enhance communication between the resident and staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 4 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure the care plan for Resident 71 was revised following a fall on 4/1/21, according to the facility's policy and procedure. Residents Affected - Few This deficient practice had the potential to result in recurrent falls for the resident. Findings: A review of the admission Record indicated Resident 71 was admitted the facility on 3/19/21 with diagnoses that included muscle wasting, difficulty in walking, osteoporosis (condition in which bones become weak and brittle) and history of falling. A review of Resident 71's Situation, Background, Assessment, and Request (SBAR) Communication Form and Progress note dated 4/1/21 indicated the resident was found on the floor on 4/1/21. A review of Resident 71's care plan did not indicate the facility staff revised the resident's care plan following the fall on 4/1/21. During a concurrent interview and record review with Registered Nurse 1 (RN1) on 6/18/21 at 9:14 AM, RN1 stated there was no care plan developed after Resident 71's fall on 4/1/21. A review of the facility's Policy and Procedure titled, Assessing Falls and Their Causes, dated 10/2010 indicated when a resident falls, appropriate interventions taken to prevent future falls should be documented in the resident's medical record. A review of the facility's Policy and Procedure titled, Care Plans - Comprehensive, dated 10/2010 indicated assessments of residents were ongoing and care plans were revised as information about the resident and resident's condition change. The Care Planning/Interdisciplinary Team was responsible for reviewing and updating of care plans when there has been a change in resident's condition and a desired outcome was not met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 5 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure on peripheral intravenous (IV) catheter insertion, by failing to date, time and initial the IV dressing for one of two sampled residents (Resident 179). Residents Affected - Few This deficient practice had the potential for licensed nurses not to change the intravenous site or dressing on time, placing Resident 179 at risk for IV related infection. Findings: A review of Resident 179's admission Record indicated Resident 179 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of osteomyelitis (inflammation of the bone caused by infection), surgical aftercare, and diabetes (a long-term disorder characterized by high blood sugar). A review of Resident 179's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 5/28/2021, indicated Resident 179 had a moderately impaired cognition (mental process involved in knowing, learning, and understanding things). Resident 179 required extensive assistance from staff with activities of daily living including bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 179's Physician's Order dated 6/12/21, indicated an order of Cefepime Solution 1 gram (unit of measurement) IV one time a day for status post incision and drainage (I & D) of left leg/foot for 21 days. A review of Resident 179's IV Administration Record, indicated Cefepime 1 gram IV every 24 hours was administered from 6/13/21 to 6/18/21. During an observation on 6/15/21 at 10:21 a.m., Resident 179 was lying in bed with an IV access to the right antecubital (anterior to the elbow) area. The IV site was not dated, timed, or initialed. Resident 179 stated she has infection on her left leg and foot. During an observation and concurrent interview on 6/15/21 at 10:21 a.m., Registered Nurse 2 (RN 2) stated Resident 179's IV access was on her right antecubital area. RN2 stated the IV site dressing label does not have a date, time, and initial of the nurse who started the IV. RN 2 stated Resident 179 was receiving IV antibiotics because of infected wounds on her left leg and foot. RN 2 stated the licensed nurse who started the IV need to label the IV dressing to indicate when the IV dressing needed to be changed and replaced to prevent infection. During an interview on 6/16/21 at 2:48 p.m., the Director of Nursing (DON) stated the licensed nurse who started the IV access need to write the date, time and initial on the IV dressing label to indicate when it was placed and when it will be changed to prevent infection. DON stated IV sites will be rotated every 72 hours. A review of the facility's policy and procedure, titled Peripheral IV Catheter Insertion, updated January 2021, indicated label dressing with date, time, catheter gauge and length, and initials of person who inserted catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 6 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its hemodialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working) access care policy and procedure by failing to provide an emergency kit/clamp at bedside for one of two sampled hemodialysis residents (Resident 177). Residents Affected - Few This deficient practice had the potential for licensed nurses not able to control bleeding when heavy bleeding occurs from Resident 177's hemodialysis site. Findings: During an observation on 6/15/2021 at 10:11 a.m., Resident 177 was lying in bed with an arteriovenous (AV) shunt (an abnormal connection between an artery and a vein to help with hemodialysis treatment) on the right upper arm. Resident 177 stated his dialysis were done on Mondays, Wednesdays, and Fridays. There was no emergency kit/clamp observed at the bedside. During an observation and concurrent interview on 6/15/2021 at 10:11 a.m., Registered Nurse 2 (RN 2) stated Resident 177's AV shunt was on her right upper arm. RN 2 stated Resident 177 has no emergency kit/clamp at the bedside. RN 2 stated dialysis residents need to have an emergency kit/clamp available at bedside. It is used to control bleeding in an emergency (a serious, unexpected, and dangerous situation requiring immediate action) situation. RN 2 stated Emergency kit contains tourniquet (a device for stopping the flow of blood through a vein or artery by compressing a limb), a clamp, abdominal pad, gauze, and tape. During an interview on 6/16/2021 at 2:11 p.m., the Director of Nursing (DON) stated all dialysis residents need to have an emergency kit with clamp, tourniquet, gauze, and tape readily accessible at the bedside. The DON stated dialysis residents with bleeding from a dialysis access need to be transferred to the hospital immediately. The DON stated emergency kit is important to control bleeding while waiting for paramedics (a health care professional who provides advanced emergency medical care for critical and emergent patients) to arrive. A review of Resident 177's admission Record indicated Resident 177 was admitted to the facility on [DATE] with diagnoses of end stage renal disease (loss of kidney function that filter wastes and excess fluids from the blood, which are then excreted in the urine), dependence on renal (kidney) dialysis, and diabetes (a long-term disorder characterized by high blood sugar). A review of Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 6/8/2021, indicated Resident 177 had a moderately impaired cognition (mental process involved in knowing, learning, and understanding things). Resident 177 required extensive assistance from staff with activities of daily living including bed mobility, transfer, walking, dressing, toilet use, and personal hygiene. A review of Resident 177's Physician Order dated 6/11/2021, indicated an order for dialysis every Monday, Wednesday, and Friday. A review of Resident 177's Nursing Facility Pre-Dialysis and Post-Dialysis Assessment, indicated Resident 177 had dialysis on 6/4/2021, 6/7/2021, 6/9/2021, 6/11/2021, and 6/14/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 7 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0698 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure, titled Hemodialysis Access Care, revised September 2010, indicated if there is major bleeding from site during post dialysis, apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on central lumens, dialysis E-kit provided at bedside consist of gauze, tape, and abdominal pads. This is a medical emergency. Do not leave resident alone until emergency services arrive. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 8 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses and nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for two of five sampled staff members (Registered Nurse 2, and Certified Nurse Assistant 1). This deficient practice placed the residents at risk for not having their needs met safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being by competent staff. Findings: a. A review of Registered Nurse 2's (RN 2's) Employee Information Form indicated RN 2 was hired on [DATE] as a Registered Nurse for the facility's Nursing Department. RN 2's employee file included a copy of her Registered Nurse licensure, which expires on [DATE]. RN 2's employee file included a facility form titled, RN Annual Performance Evaluation, which was completed and signed by the Director of Nursing (DON) and RN 2 on [DATE]. RN 2's RN Annual Performance Evaluation indicated the following categories were evaluated: Administrative Functions, Personnel Functions, Nursing Care Functions, Staff Development, Safety and Sanitation, Care Plan and Assessment Functions, Resident Rights, and Skills Check. The Skills Check portion of RN 2's RN Annual Performance Evaluation indicated RN 2 is competent in the following: (1) blood glucose monitoring, (2) gastrostomy tube (a tube inserted through the abdomen and into the stomach to provide a route for tube feeding and medications) checking, care, and administration of medications, (3) medication administration, (4) intravenous therapy (IV, medical technique that delivers fluids, medications, and nutrition directly into a person's vein) monitoring and care, (5) emergency care/oxygen and hand-held nebulizer (HHN, a medical device used by patients when receiving aerosol treatments), admission assessment and care planning, (6) wound identification and treatments, (7) change of condition identification, monitoring and care, (8) infection control (handwashing, placement of foley catheter, handling gloves, review of policy and procedures), and (9) pronouncement of expired residents. RN 2's employee file did not contain any other evaluation form for 2020 or 2021. b. A review of Certified Nursing Assistant 1's (CNA 1's) Employee Information Form indicated CNA 1 was hired on [DATE] as a Certified Nursing Assistance for the facility's Nursing Department. CNA 1's employee file included a copy of her Nurse Assistant certification, which expires on [DATE]. CNA 1's employee file included a facility form titled, Employee Performance Review that was not dated or signed by CNA 1 or the supervisor signatures that completed the form. CNA 1's employee file included a facility form titled, Report of Performance Evaluation, which was dated [DATE], indicated it was signed by CNA 1 and the person who performed the evaluation. CNA 1's employee file did not contain a performance or skills evaluation form from 2019 and 2020. During an interview with the Director of Staff Development (DSD) on [DATE] at 3:30 pm, she stated it is important to perform annual evaluations and skills validation to ensure nursing staff provide appropriate care and fulfill the needs of the residents. During an interview with the Director of Nursing (DON) on [DATE] at 3:48 pm, the DON stated she was very busy last year during the pandemic and she completed a couple of RN and LVN evaluations in 2020 and 2021. The DON stated the facility should conduct performance evaluations every year to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 9 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recognize the work of the employee and to assess the accuracy of the employee's work to ensure they are competent to care for the residents. The DON stated the completed evaluation form should be signed by the employee being reviewed and by the person performing the review. The DON stated the completed and signed evaluation form should then be filed in the employees' file and not discarded. The DON stated she performs the evaluations for the licensed nurses (RNs and LVNs), then gives the signed and completed evaluation form to the DSD to add to the employee's file. The DON stated the facility does not have a policy related to performing annual evaluations and skills validation. A review of the facility's Employee Handbook, undated, indicated formal written performance reviews are usually scheduled to coincide with an employee's employment anniversary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 10 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure as needed (PRN, medications only used when necessary) orders for psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) are limited to 14 days, unless the prescribing practitioner documents a rationale to extend the medication for one of 18 sampled residents (Resident 54). This deficient practice had the potential to place Resident 54 at risk of receiving unnecessary psychotropic medication. Findings: A review of Resident 54's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included neoplasm (new and abnormal growth of tissue) of bladder and colon, generalized intra-abdominal (occurring within the abdomen) and pelvic mass and lump, difficulty walking, and anxiety disorder. A review of Resident 54's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 5/6/2021, indicated the resident is cognitively intact. The MDS indicated Resident 54 required limited assistance with walking, toilet use, and personal hygiene. The MDS indicated Resident 54 required extensive assistance with bed mobility and transfers. The MDS indicated Resident 54 reported feeling down, depressed, or hopeless nearly every day. A review of Resident 54's Order Summary Report for active orders for May 2021, indicated an order for Lorazepam (medication used to treat anxiety) tablet 1 milligram (mg), 1 tablet to be given by mouth every six hours as needed for anxiety manifested by inability to relax with no documentation of an end date for this medication order. The Order Summary Report for active orders dated 5/3/2021, indicated an order for non-pharmacological interventions for anxiety, which included: (1) music/radio/television, (2) activity/exercise, (3) redirection/refocus/diversion, (4) removal of stimuli, (5) 1:1 conversation, (6) verbal cues/prompting/encouraging, (7) reassurance/orientation, and (8) massage. A review of the facility's document titled, Informed Consent, indicated the document is to be completed before treatment is initiated with psycho therapeutic drugs. The Informed Consent indicated the prescribing physician informed Resident 54 of the proposed treatment plan of Lorazepam 1 mg, to be given every six hours as needed for anxiety. Resident 54's informed consent contained one signature, which was from a facility representative with the title Registered Nurse (RN) and dated on 5/3/2021. The informed consent indicated the resident's signature is not required on the form. During an interview with the Director of Nursing (DON) on 6/16/2021 at 2:19 pm, she stated the Medical Doctor (MD) should review and reorder PRN psychotropic drugs after 14 days from the initial order date. The DON stated the Assistant Director of Nursing (ADON), Social Service Director (SSD), and the MD are responsible for deciding if the resident still needs the psychotropic medication. The DON stated the Registered Nurse Supervisor (RN 2) is in charge of reviewing prescribed PRN psychotropic medication orders every month. The DON stated PRN psychotropic medication orders need to be reviewed 14 days after the initiation of the order and the MD needs to provide a rationale and duration for extended use if applicable. The DON stated RN 2 did not review Resident 54's PRN Lorazepam order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 11 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0758 The DON stated the risk for residents receiving unnecessary medications can lead to potential harm. Level of Harm - Minimal harm or potential for actual harm During an interview with RN 2 on 6/16/2021 at 2:30 pm, she stated PRN psychotropic medication orders should only be for a duration of 14 days when it is ordered by the MD for the first time for a resident. RN 2 stated after the initial 14 days, the PRN psychotropic medication order will be reviewed. RN 2 stated an initial order from Resident 54's previous chart of PRN Lorazepam tablet 1 mg, to be given every six hours as needed for anxiety was ordered by the MD from 4/19/2021 and stopped in 14 days on 5/3/2021. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 12 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Rehabilitation Department failed to ensure Restorative Nursing Aid (RNA) services were continued for one of three sampled residents (Resident 17) when she was re-admitted from a General Acute Care Hospital (GACH). Residents Affected - Few This deficient practice resulted in delayed RNA services for Resident 17 and placed the resident at risk for a decline in range of motion. Findings: A review of Resident 17's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included osteoarthritis (degeneration of joint cartilage and the underlying bones, causing pain and stiffness) of right and left hips, difficulty in walking, muscle wasting, and morbid (severe) obesity. The admission Record indicated Resident 17 was discharged to the acute hospital and stayed in the acute hospital from [DATE] to 5/29/2021 before being re-admitted to the facility. A review of Resident 17's care plan dated on 3/26/2021, indicated resident requires assistance with the following activities of daily living (ADLs): bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The care plan goal is Resident 17 will have increased Activities of Daily Living (ADL) participation. Resident 17's care plan intervention included a RNA for bilateral lower extremities (BLE), Active Assisted Range of Motion (AAROM), five times a week. A review of Resident 17's PT Evaluation and Plan of Treatment notes dated 3/27/2021, indicated she is certified to receive physical therapy five times a week for 12 weeks from 3/27/2021 to 6/18/2021. A review of Resident 17's Order Summary Report covering physician orders from 3/29/2021 to 6/30/2021 indicated an order for an RNA to provide BLE AAROM for 15 minutes once a day, five times a week or as tolerated was discontinued on 5/18/2021. The Order Summary Report indicated that Resident 17 was transferred to the emergency room for evaluation of right hip pain on 5/25/2021. The Order Summary Report indicated an order for PT evaluation and treatment if needed on 5/29/2021. A review of Resident 17's Minimum Date Set (MDS, a resident assessment and care-screening tool), dated 4/1/2021, indicated the resident is cognitively intact. The MDS indicated Resident 17 required extensive assistance with bed mobility, dressing, toilet use, and maintaining personal hygiene. The MDS indicated Resident 17 was fully dependent on staff to assist with transfers and bathing. The MDS indicated resident and direct care staff believe resident is capable of increased independence. A review of Resident 17's care plan dated on 5/17/2021, indicated resident requires RNA services due to a risk for decline in range of motion. The care plan indicated the goal for Resident 17 was to prevent further decline in AAROM. Resident 17's care plan intervention included a RNA for BLE AAROM for 15 minutes a day, five times a week, or as tolerated. A review of Resident 17's PT Discharge summary dated [DATE] included discharge recommendations for a restorative program for AAROM of BLE 15 minutes, once a day to patient tolerance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 13 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation in Resident 17's room and a concurrent interview with the resident on 6/15/2021 at 9:50 am, the resident was lying on a low air loss mattress. Resident 17 stated she has been in the facility since March and received only three weeks of rehabilitation services. Resident 17 stated after rehabilitation services stopped, there was an RNA who only came for two days for range of motion exercises. Resident 17 stated that the plan is for her to return home, but she cannot stand up independently. Resident 17 stated she used to walk around her home with a walker prior to being hospitalized . During an interview with Physical Therapist 1 (PT 1) and concurrent record review on 6/17/2021 at 1:32 pm, she stated Resident 17 was admitted on [DATE] for rehabilitation services. PT 1 stated the case manager discharged Resident 17 from rehabilitation services due to no medical coverage and the resident will be placed on an RNA program. PT 1 stated a physician order is entered for an RNA to provide range of motion exercises for the resident and the physician order is printed, then placed in the resident's chart. PT 1 stated the RNA is informed of physician orders through Cerner (electrical charting system used by the RNA) and the RNA is then trained by a PT on range of motion exercises specific to the resident the physician order is for. PT 1 stated RNA treatment was ordered on 5/12/2021 after Resident 17 was discharged from rehabilitation services. PT 1 stated Resident 17 was discharged to hospital on 5/25/2021 and re-admitted on [DATE] with a PT evaluation order. PT 1 stated Resident 17 exhausted her insurance coverage for PT. PT 1 stated RNA services should be provided, but there was no order for RNA services after Resident 17 was readmitted . PT 1 stated if range of motion exercises are not provided, Resident 17's extremity might be contracted, pressure sore can develop, and there will be a decline in ADLs and quality of life. During an interview with Physical Therapist 2 (PT 2) on 6/18/2021 at 8:47 am, she stated the Rehabilitation Director normally prints out a daily order sheet listing which residents need to be treated. PT 2 stated she did not know Resident 17 was discharged to the hospital and readmitted with a new order for PT evaluation. PT 2 stated she thought Resident 17's order for RNA services resumed from previous order. During an interview with the Rehabilitation Director (RD) on 6/18/2021 at 8:57 am, he stated Resident 17 had a new PT evaluation order after readmission and was waiting for insurance authorization. The RD stated, It was 100% my fault. The RD stated he forgot to resume the order for RNA services for Resident 17. A review of the facility's Policy and Procedure titled, Nursing Services, revised on 1/28/2015, indicated skilled care and rehabilitation/restorative services are provided based on the strengths and needs identified from the comprehensive interdisciplinary assessment and care planning process. The facility's policy indicated the resident is the center of the planning process and has a treatment plant that is directed to increasing resident's improvement and prevention of deterioration of ADLs, transfers, ambulation, and toileting. A review of the facility's admission Policy and Procedure indicated rehabilitation services are coordinated and integrated to maximize each patient's level of functional independence and interventions shall be consistent with identified treatment goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 14 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 36's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damaged brain tissues caused by lack of oxygen to the area) due to embolism (obstruction of an artery, typically by a clot of blood or an air bubble), hypertension (high blood pressure), and of history of coronavirus disease (COVID-19, an infectious disease affecting the respiratory system). Residents Affected - Some A review of Resident 36's MDS, dated [DATE], indicated the resident's cognition (ability to understand) was moderately impaired. During an observation in Resident 36's room on 6/15/2021 at 11:48 am, the resident was lying in bed, awake, and alert with a nasal cannula (NC, oxygen tubing) in his nostrils. Resident 36's NC was not labeled with a date and time of when it was changed. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/15/2021 at 11:50 am, he stated Resident 36's NC was not labeled with a date and time of when it was changed. During an interview with Licensed Vocational Nurse 5 (LVN 5) on 6/15/2021 at 11:52 am, she stated NC was not labeled with a date and time of when it was changed. LVN 5 stated the plastic bag NCs are stored in a bag when it was not in use. The NC was labeled 3/16/2021. LVN 5 stated the plastic bag and NC should be changed weekly and labeled with the resident's name, room number, and date for infection control purposes. LVN 5 stated if the NC and plastic bag used to hold the NC is not changed on a weekly basis, bacteria or virus can spread. A review of Resident 36's Order Summary Report indicated a physician order for 2 - 4 L/min of oxygen via NC as needed for oxygen saturation less than 92%. A review of Resident 36's care plan titled initiated on 7/20/2019, indicated the resident is at risk for shortness of breath secondary to diagnoses of hypertension (high blood pressure) and hyperlipidemia (high levels of fats in the blood). Resident 36's care plan goal indicated the resident will be free from episodes of shortness of breath. Resident 36's care plan interventions include the monitoring of the resident's oxygen saturation and the administration of oxygen as needed. During an interview with the Director of Nursing (DON) on 6/16/2021 at 2:34 pm, she stated the NC needs to be changed weekly. The DON stated there is a designated licensed nurse who works on Sundays from 11:00 pm to 7:00 am and changes the tubing for all residents who are prescribed oxygen. The DON stated the facility does not have a policy stating how often the oxygen tubing is changed. The DON stated the purpose of changing oxygen tubing weekly is for infection control purposes. 4. A review of Resident 54's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included neoplasm (new and abnormal growth of tissue) of bladder, acute kidney failure, hydronephrosis (swelling of the kidney due to build-up of urine that is unable to drain out from the kidney to the bladder due to an obstruction), and history of UTI. A review of Resident 54's MDS, dated [DATE], indicated the resident is cognitively intact. The MDS indicated Resident 54 required limited assistance with walking, toilet use, and personal hygiene. The MDS indicated Resident 54 required extensive assistance with bed mobility and transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 15 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 Level of Harm - Minimal harm or potential for actual harm During an observation in Resident 54's room and a concurrent interview with the resident on 6/15/2021 at 10:22 am, there are two undated nephrostomy drainage bags on the resident's left and right sides. The gauze dressing over the left and right nephrostomy insertion sites are clean and dry. Resident 54 stated the nephrostomy tubes were inserted in February 2021. Resident 54 stated the treatment nurse changes the urine collecting bag weekly. Residents Affected - Some A review of Resident 54's Order Summary dated 6/17/2021, indicated left and right nephrostomy care every day shift. The Order Summary did not have a clear instruction. During an observation of Treatment Nurse (TX 1) in Resident 54's room on 6/17/2021 at 10:05 am, TX 1 was performing dressing change to the left and right nephrostomy insertion sites. TX 1 prepared a clean tray with the following supplies: clean gloves, waste bag, gauze dressing, tegaderm (transparent medical dressing to cover and protect wounds), sterile (free from bacteria or other living microorganisms) normal saline, and scissors. TX 1 removed Resident 54's contaminated nephrostomy dressings. There were no signs of redness, bleeding, or inflammation (when part of the body becomes reddened, swollen, hot, and painful; a reaction to injury or infection) at the left and right insertion sites. TX 1 used sterile normal saline to clean the left and right nephrostomy insertion sites, applied clean drain dressing, and covered the site with a dated tegaderm. TX 1 performed hand hygiene and appropriate donning and doffing of gloves. A review of the facility's Policy and Procedure titled, Nephrostomy Tube, Care, dated 10/2010, indicated the purpose of the facility policy is to provide guidelines for the care of the resident with a nephrostomy tube. The facility's policy indicated the supplies needed for a nephrostomy dressing change includes: sterile 4 x 4 (sizing of the dressing, four inches by four inches) drain dressings, povidone-iodine (a product used as an antiseptic for cleansing of the skin) swabs, sterile saline, clean gloves, sterile gloves, disposable underpad, sterile drape, and waste bag. During an interview with TX 1 on 6/17/2021 at 11:45 am, she stated the physician's order did not include a detailed description of how to perform nephrostomy care. TX 1 stated Resident 54 is the first resident she has performed nephrostomy care on and she was trained by the previous treatment nurse. TX 1 stated she did not know changing the dressing on the nephrostomy site required sterile technique as she was not taught that. TX 1 stated sterile technique is needed for genitourinary (GU, relating to the genital and urinary organs) procedures for infection control. TX 1 stated if the GU system is infected, the resident may become septic (infected with microorganisms) and die. 5. A review of Resident 68's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive and dependence on supplemental oxygen. A review of Resident 68's MDS, dated [DATE], indicated the resident's cognition was severely impaired. During an observation in Resident 68's room on 6/15/2021 at 10:03 am, the resident was sitting on the edge of the bed with two physical therapists assisting her. Resident 68 was returned to a lying position on her bed with the call light within reach. Resident 68 had a NC in her nostrils and her NC was not labeled with the date and time of when it was changed. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 6/15/2021 at 10:07 am, he stated Resident 68's NC was not labeled with a date and time of when it was changed. LVN 2 stated the NC and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 16 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the plastic bag used to hold the NC when it is not in use. LVN 2 stated the NC is scheduled to change every Sunday night. LVN 2 stated the NC is changed weekly for infection control and to prevent germs from building up. A review of Resident 68's Order Summary Report indicated a physician order for the resident to receive oxygen at 2 L/min via NC continuously and to maintain the resident's oxygen saturation at greater than 92%. A review of Resident 68's care plan for oxygen use, initiated on 5/13/2021, indicated the resident is on supplemental oxygen use for shortness of breath. The goal was for Resident 68's shortness of breath will be relieved with the administration of oxygen. Resident 68's care plan interventions include oxygen therapy at 2 L/min via NC. During an interview with the Director of Nursing (DON) on 6/16/2021 at 2:34 pm, she stated the NC needs to be changed weekly. The DON stated there is a designated licensed nurse who works on Sundays from 11:00 pm to 7:00 am and changes the tubing for all residents who are on prescribed oxygen. The DON stated the facility does not have a policy stating how often the oxygen tubing is changed. The DON stated the purpose of changing oxygen tubing weekly is for infection control purposes. Based on observation, interview, and record review, the facility failed to observe infection control measures for five of six sampled residents (Residents 178, 7, 36, 54, 68) by failing to: 1. Ensure Resident 178's indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag usually attached to the thigh) tubing and drainage bag were not touching or on the floor. 2. Ensure Resident 7's indwelling catheter tubing was not on the floor 3. Ensure Resident 36's oxygen tubing was labeled with the date and time it was changed by the licensed nurse. 4. Ensure Resident 54's nephrostomy (an opening made between the kidney and the skin on your back to allow urine to drain from the kidney through a thin, flexible tube to a collection bag) insertion site dressing was completed with a sterile technique by the licensed treatment nurse. 5. Ensure Resident's 68's oxygen tubing was labeled with the date and time it was changed by the licensed nurse. These deficient practices had the potential to result in contamination of the resident's care equipment and placed Residents 178, 7, 36, 54, 68 at risk for infection. Findings: 1. During an observation on 6/15/2021 at 10:14 a.m., Resident 178 was lying in bed. The resident's foley catheter tubing and drainage bag were on the floor. During an observation and concurrent interview on 6/15/2021 at 10:14 a.m., Registered Nurse 2 (RN 2) stated Resident 178's foley catheter tubing and drainage bag were on the floor. RN 2 stated foley (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 17 of 18 Printed: 05/15/2026 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 055187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some catheter tubing and drainage bag should be hanging on the bed frame, free of kinks and positioned lower than the bladder (a muscular sac that stores urine). Foley catheter tubing and drainage bag should not be touching the floor to prevent infection. During an interview on 6/16/2021 at 2:00 p.m., Licensed Vocational Nurse 4 (LVN 4) stated foley catheter that touches the floor is considered contaminated and a possible source of germs (refers to bacteria, viruses, and fungi that can cause a disease). During an interview on 6/16/2021 at 2:07 p.m., the Director of Nursing (DON) stated foley catheter tubing and drainage should be placed below the bladder to drain well. Foley catheter tubing and drainage bag should not touch the floor or on the floor to prevent infection and contamination. A review of Resident 178's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses of squamous cell carcinoma (a type of cancer that begins in the skin and may spread to other parts of the body) of the skin, surgical aftercare, and weakness. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 6/8/2021, indicated Resident 178 had an intact cognition (mental process involved in knowing, learning, and understanding things). Resident 177 required extensive assistance from staff with activities of daily living including bed mobility, dressing, and personal hygiene. 2. A review of Resident 7's admission Record, indicated the resident was admitted to the facility on [DATE]. Resident 7's diagnoses included history of paraplegia (paralysis of the legs and lower body), generalized muscle weakness, urine retention (difficulty urinating and completely emptying of the bladder), major depressive disorder (a mental health disorder characterized by loss of interest in activities causing impairment in daily life), resistance to multiple antibiotics (medicine that inhibits growth of or destroys microorganisms), and neuromuscular (relating to nerves and muscle) dysfunction of the bladder. During an observation on 6/15/2021 at 11:23 a.m., Resident 7's indwelling catheter tubing was on the floor. During an observation and concurrent interview on 6/15/2021 at 11:45 a.m., LVN 1 stated the urinary catheter tubing should not be on the floor and could result in infection because the floor is not clean. During an interview on 6/18/2021 at 8:09 a.m., LVN 2 stated the urinary catheter needed to be changed because it was contaminated from touching the floor and placed the resident at risk for infection. A review of the facility's policy and procedure, titled Catheter Care, Urinary, revised September 2014, indicated for staff to keep the catheter tubing and drainage bag off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055187 If continuation sheet Page 18 of 18