Health inspection·September 11, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to have the current Advance Health Care Directive (AD- legal document that gives instructions about healthcare decisions and to name someone to make decisions if unable) for one of eight sampled residents (Resident 5). This failure resulted in Resident 5's first and second Designated Agent (DA) for Power of Attorney for Health Care (POA- person who will make health care decisions for you when you cannot) not being notified by the facility of Resident 5's death. Findings:A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in January 2012 with multiple diagnoses including multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage between the brain and the body), epilepsy (seizure disorder), and dysphagia (difficulty swallowing foods and liquids).Further review of Resident 5's admission Record indicated Resident 5 was her own Responsible Party (RP), Resident 5's family member was listed as emergency contact (EC) 1 and a friend was listed as the EC 2. Resident 5's first and second DAs were listed as the ECs 3 and 4.A review of Resident 5's Minimum Data Set (MDSfederally mandated assessment tool), Cognitive Patterns, dated 7/5/25, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 9 out of 15 that indicated Resident 5 had moderate cognitive impairment. A review of Resident 5's order, dated 1/5/19, indicated .Resident Is Capable of Understanding Rights, Responsibilities, And Informed Consent . A review of Resident 5's Advance Health Care Directive, dated 11/14/11, indicated Resident 5's Power of Attorney for Healthcare, Designated Agents (DA) were DA 1 and DA 2. The document did not indicate that Resident 5's EC 1 and EC 2 were the DAs according to Resident 5's AD. A review of Resident 5's SBAR [Situation, Background, Assessment, Recommendation] Communication Form, dated 8/14/25, indicated .pt [patient] unarousable with sternal rub, pt moaned but did not open eyes .send out to hospital for further evaluation .Name of Family/Health Care Agent Notified: . [EC 1] . A review of Resident 5's Progress Note, dated 8/18/25, indicated .At approximately 2215 [10:15 p.m.], this LN [Licensed Nurse], observed res [resident] to be sleeping peacefully with eyes closed. Upon assessment res was not breathing and no vital signs obtained. RN [registered Nurse] notified and pronounced resident deceased . [EC 1] was informed of resident's passing. [EC 1] coordinated with Social Services regarding transportation arrangements. Res body is expected to be transported .with assistance from res good friend . A review of Resident 5's Progress Note, dated 8/19/25, indicated .Spoke with resident's [EC 1] to confirm mortuary resident will be going to . During a telephone interview on 9/4/25 at 10:57 a.m. with Resident 5's DA 2, DA 2 stated she was notified of Resident 5's death when she received a call from the mortuary. DA 2 stated she was not notified by the facility of Resident 5's death. DA 2 stated she was supposed to be the second emergency contact for Resident 5 and DA 1 was the main contact. DA 2 stated DA 1 was not notified of Resident 5's death by the facility either. DA 2 stated she spoke with the facility, but the facility was unable to locate the AD. Page 1 of 8 055776 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DA 2 stated she faxed Resident 5's AD to the facility in 2013. DA 2 stated the AD was created in 2011. DA 2 stated she was not aware if it had been changed to indicate Resident 5's EC 1 was made a DA. During an interview on 9/11/25 at 2:40 p.m. with the Director of Nursing (DON), the DON stated Resident 5's EC 1 was the person the facility contacted. The DON stated that EC 1 was in the facility frequently and staff discussed concerns with her. The DON confirmed that there was no AD in Resident 5's electronic record. The DON stated all documents since 2022 had been uploaded into the electronic record. The DON stated there was no AD for 2011 in Resident 5's chart.During an interview on 9/11/25 at 3 p.m. with the Social Services Director (SSD), the SSD stated that Resident 5's EC 1 was her Responsible Party (RP). The SSD stated DA 1 was under the impression that she was EC 1 and the SSD notified DA 1 what was on the admission Record. The SSD stated Resident 5's EC 1 was the POA. Reviewed with the SSD that Resident 5's AD had been faxed to the facility in 2013 by DA 2. The SSD stated that electronic charting changed in 2022, but the document should have been uploaded to the new system. The SSD stated Resident 5's 2011 AD would still be in effect unless there was new documentation showing it was revoked or changed. During an interview on 9/11/25 at 4:07 p.m. with the Medical Records Assistant (MRA), the MRA stated she located Resident 5's AD dated 11/14/11 in past files. The MRA confirmed the document indicated DA 1 and DA 2 are the designated agents and that there was no other document that superseded it. During a subsequent interview on 9/11/25 at 4:10 p.m. with the SSD, reviewed Resident 5's AD provided by the MRA. The SSD stated she had no knowledge of it, and it should have been passed on to the new electronic record. The SSD stated, [AD] was buried. When asked what the consequence was of not having the correct information according to the AD, the SSD stated, The proper person was not making the decisions. The [EC 1] was always involved, so we kept going to her. Was incorrect. A review of the facility's Policy and Procedure (P&P) titled Advance Directives, dated 9/22, indicated .The resident has the right to formulate and advance directive .Advance Directives are honored in accordance with state law and facility policy . Prior to or upon admission of a resident, the social services director or designee inquires of the resident .about the existence of any written advance directives .If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff .The resident's wishes are communicated to the resident's direct care staff and physicians by placing the advance directive documents in a prominent, accessible location in the medical record . 055776 Page 2 of 8 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to protect one of eight sampled residents from physical abuse (Resident 1), when Resident 1 was struck on the face by Resident 2.This failure resulted in Resident 1 experiencing psychosocial distress and fear in the facility. Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2025 with multiple diagnoses including amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), dysphagia (difficulty swallowing food and liquids), and cachexia (extreme weight loss and muscle loss).A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/6/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMStool to assess cognition) score of 15 out of 15 that indicated Resident 1 was cognitively intact. Further review of Resident 1's MDS, Functional Abilities, dated 8/6/25, indicated Resident 1 had impairment on both sides of upper and lower extremities, was dependent for bed mobility and transfers, used a wheelchair, and was able to mobilize in the wheelchair with set up assistance. A review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation] Communication Form, dated 8/28/25, indicated .Resident notified staff, that she was allegedly struck on the face by another resident while out on patio. Skin observation completed with no redness, swelling, or bruising noted . A review of Resident 1's Progress Note, dated 8/28/25, indicated .AT 2155 [9:55 p.m.] resident came down the hall in electric wheelchair asking this nurse to call 911 because she got hit in the face by another resident in smoking area. This writer immediately notified RN [Registered Nurse] supervisor to handle situation. When arrived back to station, I advised this resident the RN supervisor was handling it. Resident stated I will get my phone and call 911 myself . A review of Resident 1's Progress Note, dated 8/29/25 at 8:14 a.m., indicated . Brought to SSD [Social Services Director] attention that res [resident] was slapped in the face by another resident. Altercation occurred in the smoking area, res was apparently in the walk way and was not able to move. Other resident made statements Get the f*** out of my way Im gonna beat your a** after comments, res was then slapped. After incident res called the police to make a report . A review of Resident 1's Progress Note, dated 8/29/25 at 1:37 p.m., indicated .Resident on monitoring for being slapped by a male resident on 8/28/25 .Kept both residents separated throughout shift .LN [Licensed Nurse] observed that resident had slight swelling and redness to left side of face. Also resident had sore to left lower lip, resident stated that the sore opened up after she was slapped by the other resident . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in August 2023 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke-blood flow to the brain is interrupted causing tissue damage), diabetes (too much sugar in the blood), and aphasia (inability to produce speech as a result of brain damage).A review of Resident 2's MDS, Cognitive Patterns, dated 5/29/25, indicated Resident 2 had a BIMS score of 6 out of 15 that indicated Resident 2 had severe cognitive impairment. Further review of Resident 2's MDS, Functional Abilities, dated 5/29/25, indicated Resident 2 was able to transfer and ambulate with set up assistance and did not use an assistive device. A review of Resident 2's SBAR Communication Report, dated 8/28/25, indicated . It is alleged that resident hit another resident with an open hand to her left temple area. This allegedly occurred after other resident told this resident he could not be out in the smoking section and told him to go inside, making him upset. This resident unable to make statement from his perspective as he does not produce clear or understandable speech at baseline . A review of Resident 2's Progress Note, dated 8/28/25 at 10:15 p.m., indicated .at 2200 055776 Page 3 of 8 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [10 p.m.] it was brought to writers attention that an alleged incident happened between this resident and another in the smoking area outside. Other resident told this resident he was not welcome to be outside and that he should go back inside. Allegedly, this resident then got in her face and hit her with an open hand .Resident was unable to give personal account of the incident due to dysphasia which is residents baseline . A review of Resident 2's Progress Notes, dated 8/29/25 at 10:09 a.m., indicated .Brought to SSD attention that resident allegedly hit a female resident near the smoking area. Res was reported to shadowbox with her then slapped her in the face. Also reported that resident was cussing, but res has dysphagia and is very hard to understand . A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in December 2025 with multiple diagnoses including burns of left and right feet, diabetes, and heart failure (heart does not pump blood as well as it should). A review of Resident 3's MDS, Cognitive Patterns, dated 7/16/25, indicated Resident 3 had BIMS score of 14 out of 15 that indicated Resident 3 was cognitively intact. During an interview on 9/11/25 at 10:15 a.m. with the Administrator (ADM), the ADM stated Resident 1 reported Resident 2 slapped her out at the smoking area on 8/28/25 at approximately 10 p.m. The ADM stated that no injuries were observed. The ADM stated Resident 2 is now having a one-to-one sitter.During an interview on 9/11/25 at 12:13 p.m. with Resident 1, Resident 1 stated incident with Resident 2 happened when she was going outside to the smoking area on the concrete path to the gazebo. Resident 1 stated Resident 2 came out of the building and told her to get out of his way. Resident 1 stated he was standing on her left side. Resident 1 reported Resident 2 was cussing at her, using expletives and then started swinging his arms. Resident 1 stated Resident 2 slapped her with open hand on the left side of her face. Resident 1 stated, When he hit me, I yelled call the police. Resident 1 stated she backed up her chair, went to the nurse's station, and asked the nurses to call the police. Resident 1 stated she then went to her room and called the police. Resident 1 stated since the incident occurred, she has seen Resident 2 walk by her room with his sitter. Resident 1 stated, He's stalking me. He shows aggression and nobody is watching him. Feel scared and unsafe where I live. During an interview on 9/11/25 at 12:40 p.m. with LN 1, LN 1 stated Resident 1 reported to her that Resident 2 hit her in the face, was aggressive with her, but still able to go into areas where she goes and it makes her uncomfortable. LN 1 stated Resident 2 now has one-to one sitter supervising him. During a concurrent observation and interview on 9/11/25 at 12:46 p.m. with Resident 2, observed one-to- one sitter at bedside. When asked if he remembered incident with Resident 1, Resident 2 answered but was difficult to understand. When asked if he remembered Resident 1, Resident 2 stated, She was being a [expletive]. Was mean to me. During an interview on 9/11/25 at 12:49 p.m. with the Nursing Assistant (NA), the NA stated she is a one-to-one sitter for Resident 2 and someone is with him all the time due to an incident that occurred. During an interview on 9/11/25 at 12:52 p.m. with LN 2, L N 2 stated she was notified by another staff that Resident 2 had struck another resident in a wheelchair in the smoking area. LN 2 stated Resident 2 was removed from the area and taken back to nursing station. LN 2 stated Resident 2 now has a one-to-one sitter with him all the time.During an interview on 9/11/25 at 1:04 p.m. with Resident 3, Resident 3 stated he saw Resident 1 coming out of the building's sliding doors and was looking out at the smoking area. Resident 3 stated he observed Resident 2 come out of the building and strike Resident 1. Resident 3 stated he observed Resident 2 strike Resident 1 on the cheek. Resident 3 stated Resident 2 willfully struck Resident 1. Resident 3 stated, She [Resident 1] was assaulted.During an interview on 9/11/25 at 2:40 p.m. with the Director of Nursing (DON), the DON stated she was aware of the incident between Resident 1 and Resident 2 at the smoking patio. The DON stated that Resident 1 told Resident 2 that he was not supposed to be out there. 055776 Page 4 of 8 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated Resident 2 replied with cussing and expletives and made contact with Resident 1's left temple. The DON stated Resident 2 now has a one-to-one sitter due to this incident. Reviewed with the DON that Resident 2 had been walking in the same hallway where Resident 1's room was. The DON stated, No reason for him to be in that hallway. No reason for that to happen. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 4/24, indicated .Our residents have the right to be free from abuse .As part of the resident abuse prevention, the administration will: .Make every attempt to protect out residents from abuse by anyone including . other residents .Identify and assess possible incidents of abuse .Protect residents during abuse investigation .A review of the facility's P&P titled Resident-to-Resident Altercations, revised 9/22, indicated . All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents .If two residents are involved in an altercation, staff: .separate the residents, and institute measures to calm the situation .identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation . 055776 Page 5 of 8 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review, the facility failed to ensure that Care Plans were updated and documentation was complete for three of eight sampled residents (Resident 1, Resident 2, and Resident 4) when Resident 1 and Resident 2 were involved in a resident-to-resident altercation and Resident 4 reported abuse by a staff member.This failure had the potential for Resident 1, Resident 2, and Resident 4 to not receive the necessary interventions to maintain psychosocial and physical wellbeing.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2025 with multiple diagnoses including amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), dysphagia (difficulty swallowing food and liquids), and cachexia (great weight loss and muscle loss).A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/6/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation] Communication Form, dated 8/28/25, indicated .Resident notified staff, that she was allegedly struck on the face by another resident while out on patio . A review of Resident 1's Progress Note, dated 8/28/25, indicated .AT 2155 [9:55 p.m.] resident came down the hall in electric wheelchair asking this nurse to call 911 because she got hit in the face by another resident in smoking area. This writer immediately notified RN [Registered Nurse] supervisor to handle situation. When arrived back to station, I advised this resident the RN supervisor was handling it. Resident stated I will get my phone and call 911 myself . A review of Resident 1's Progress Note, dated 8/29/25 at 8:14 a.m., indicated . Brought to SSD [Social Services Director] attention that res [resident] was slapped in the face by another resident. Altercation occurred in the smoking area, res was apparently in the walk way and was not able to move. Other resident made statements Get the f*** out of my way Im gonna beat your a** after comments, res was then slapped. After incident res called the police to make a report. SSD will continue to look into incident with proper follow up . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in August 2023 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke-blood flow to the brain is interrupted causing tissue damage), diabetes (too much sugar in the blood), and aphasia (inability to produce speech as a result of brain damage).A review of Resident 2's MDS, Cognitive Patterns, dated 5/29/25, indicated Resident 2 had a BIMS score of 6 out of 15 that indicated Resident 2 had severe cognitive impairment. A review of Resident 2's SBAR Communication Report, dated 8/28/25, indicated . It is alleged that resident hit another resident with an open hand to her left temple area. This allegedly occurred after other resident told this resident he could not be out in the smoking section and told him to go inside, making him upset. This resident unable to make statement from his perspective as he does not produce clear or understandable speech at baseline . A review of Resident 2's Progress Note, dated 8/28/25 at 10:15 p.m., indicated .at 2200 [10 p.m.] it was brought to writers attention that an alleged incident happened between this resident and another in the smoking area outside. Other resident told this resident he was not welcome to be outside and that he should go back inside. Allegedly, this resident then got in her face and hit her with an open hand .Resident was unable to give personal account of the incident due to dysphasia which is residents baseline . A review of Resident 2's Progress Notes, dated 8/29/25 at 10:09 a.m., indicated .Brought to SSD attention that resident allegedly hit a female resident near the smoking area. Res was reported to shadowbox with her then slapped her in the face. 055776 Page 6 of 8 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Also reported that resident was cussing, but res has dysphagia and is very hard to understand . A review of the Report of Suspected Dependent Adult/Elder Abuse, for incident between Resident 1 and Resident 2, dated 8/28/25, indicated .On August 28th, 2025 [Resident 1] reported that [Resident 2] made physical contact with her using his open hand . A review of Resident 1 and Resident 2's Care Plans did not reflect a Care Plan was initiated for either Resident 1 or Resident 2 for this incident. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in December 2015 with multiple diagnoses including chronic pulmonary obstructive disease (lung disease that blocks airflow and makes it difficult to breathe), bipolar disorder (mental disorder associated with mood swings ranging from depressive lows to manic highs), and adult failure to thrive (inability to sustain weight leading to progressive decline). A review of Resident 4's MDS, Cognitive Patterns, dated 6/2/25, indicated Resident 4 had BIMS score of 12 out of 15 that indicated Resident 4 had moderate cognitive impairment. A review of Resident 4's Report of Suspected Dependent Adult/Elder Abuse, dated 9/3/25, indicated . [Resident 4] reported [Name of CNA] was too rough during a brief change, pushing her against the wall and holding her legs. No visible injuries were observed. There were no witnesses, we will conduct an investigation .A review of Resident 4's clinical record did not reflect any documentation in the clinical record of the incident and did not reflect that a Care Plan had been initiated for this incident.During an interview on 9/11/25 at 10:15 a.m. with the Administrator (ADM), the ADM stated there was an altercation on 8/28/25 between Resident 1 and Resident 2 in the patio. The ADM stated that Resident 1 reported Resident 2 slapped her in the face. The ADM stated Resident 4 reported that a Certified Nursing Assistant (CNA) had pushed her up against the wall while changing her brief. ADM stated both incidents were reported to The Department, the Ombudsman, and law enforcement. During an interview on 9/11/25 at 2:40 p.m. with the Director of Nursing (DON), reviewed incident that occurred on 8/28/25 between Resident 1 and Resident 2. The DON confirmed that neither resident had a Care Plan for the incident. The DON stated Care Plans should have been done for Resident 1 and Resident 2. Reviewed with the DON that there was no documentation in the clinical record for the incident with Resident 4. The DON acknowledged that a Change in Condition was not done and there were no progress notes regarding incident. The DON acknowledged that a Care Plan was not initiated for incident with Resident 4. The DON stated her expectation is that incidents should be documented in the clinical record and Care Plans should be done for new incidents.A review of the facility's Policy and Procedure (P&P) titled Resident-to-Resident Altercations, revised 9/22, indicated .If two residents are involved in an altercation, staff: . make any necessary changes in the care plan approaches to any or all of the involved individuals .document in the resident's clinical record all interventions and their effectiveness .A review of the facility's (P&P) titled Care Plans, Comprehensive Person-Centered revised 12/16, indicated . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The Interdisciplinary Team must review and update the care plan: . When there has been a significant change in the resident's condition .A review of the facility's P&P titled Charting and Documentation, revised 7/17, indicated . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . The following information is to be documented in the resident medical record . Events, incidents or accidents 055776 Page 7 of 8 055776 09/11/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0657 involving the resident . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055776 Page 8 of 8