Health inspection·May 11, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their Coronavirus 2019 (COVID-19, an illness caused by a virus that can spread from person to person) mitigation plan for two of three sampled residents (Resident 1 and 2) who tested positive for COVID-19 by failing to ensure: Residents Affected - Few Resident 1's and 2's vital signs (pulse rate, temperature, respiration rate, and blood pressure) and oxygen saturation (oxygen blood level) were monitored twice a shift or every four hours while Resident 1 and 2 were on COVID-19 isolation. These deficient practices had the potential for Resident 1 and 2 to receive delayed and inappropriate care. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 4/29/2023 with diagnoses which included pneumonia (an infection that affects one or both lungs) due to COVID-19. During a review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 4/21/2023 with diagnoses which included COVID-19. During an interview, on 5/11/2023 at 12:24 pm, the Infection Prevention Nurse (IPN nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated, Resident 1 went to the hospital on 4/22/2023 and tested positive for COVID-19 in the hospital. Resident 1 was readmitted by the facility and placed on COVID-19 isolation on 4/29/2023. The IPN stated, Resident 1 was taken off COVID-19 isolation on 5/3/2023. The IPN stated, Resident 2 was admitted by the facility with COVID-19 on 4/21/2023, and was placed on COVID-19 isolation on 4/21/2023 and was taken off COVID-19 isolation on 4/29/2023. During a review of Resident 1's Medication Administration Records (MARs), dated 4/1/2023--4/30/2023 and dated 5/1/2023--5/31/2023, indicated Resident 1's oxygen saturation was monitored only once a shift while Resident 1 was on COVID-19 isolation from 4/29/2023--5/3/2023. Resident 1's vital signs were not documented on the MARs. During a review of Resident 1's Weights and Vitals Summary indicated Resident 1's blood pressure was monitored on 4/30/2023 at 10:01 am, on 5/2/2023 at 5:38 pm, on 5/3/2023 at 3:18 am, and on 5/3/2023 at 6:35 pm. The Weights and Vitals Summary indicated Resident 1's temperature was monitored on 4/30/2023 at 10:01 am, on 5/2/2023 at 5:39 pm, on 5/3/2023 at 3:19 am, and on 5/3/2023 at 6:36 pm. The Weights and Vitals Summary indicated Resident 1's pulse was monitored on 4/30/2023 at 8:41 am, on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055187 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 05/11/2023 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)