Health inspection·January 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to assist the resident meal at eye level for one of one sample resident (Resident 38). Residents Affected - Few This failure had the potential to result in the Resident 38's dignity was not maintained. Findings: During a review of Resident 38's admission Record (AR), the AR indicated the facility admitted Resident 38 on 6/29/2023, with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 38's Minimum Data Set (MDS, a resident assessment and screening tool), dated 12/25/2024, indicated Resident 38 had clear speech, understood others, and made self-understood. Resident 38 required partial/moderate assistance (helper dose less than half the effort) for upper body dressing and chair/bed-to-chair transfer. During an observation on 1/21/2025 at 10:12 am, in Resident 38's room, Resident 38 was sitting up in bed and the bed was at the lowest position. Certified Nursing Assistant 2 (CNA2) was standing next to Resident 38's bed assisting/feeding Resident 38 with ice cream. CNA 2 was bending over to feed Resident 38. During a concurrent interview, CNA2 stated, Resident 38's bed was at the lowest position for fall risk. CNA2 stated, CNA2 should assist resident feeding at eye level for respect of resident's dignity. During an interview on 1/22/2025 at 3:21 pm, Licensed Vocational Nurse 2 (LVN 2) stated, staffs should feed Resident 38 at eye level for resident's dignity and safety. LVN 2 stated, it was easy for staff to observe if resident was choking when staff assisting/feeding resident meal at eye level. During a review of the facility's policy and procedure titled, Privacy and Dignity, dated 2/9/2024, indicated The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. The facility promotes independence and dignity in dining. Page 1 of 26 056228 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 19's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), sepsis (a life-threatening complication of an infection), and dementia (thinking and social symptoms that interferes with daily functioning). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/29/24, the MDS indicated Resident 19 was cognitively intact (ability to understand and process thoughts), and required substantial/maximal assistance with chair/bed to chair transfer. The MDS indicated Resident 19 was dependent with shower/bathe self, lower body dressing and needed extensive assistance with mobility and activities of daily living (ADLs). During a review of Resident 19's History & Physical (H&P), dated 4/12/24, the H&P indicated Resident 19 had the capacity to understand and make decisions. During a concurrent interview and record review, on 1/21/25, at 2:58 p.m., with Registered Nurse 1 (RN 1), Resident 19's Physician Orders for Life-Sustaining Treatment (POLST) was reviewed. The POLST indicated Resident 19 did not have an AD. There was no AD Acknowledgment Form found in Resident 19's clinical record. RN 1 stated a copy of the AD Acknowledgement Form should be in the chart indicating resident/responsible party were informed of the resident's rights to accept or refuse treatments and option to formulate an advance directive. During an interview on 1/21/25, at 3:01 p.m., with the Social Services Director (SSD), the SSD stated upon admission/readmission, all residents were asked about advance directive in case there were changes in the residents' care or wishes. The SSD stated if the resident has the capacity to understand and make medical decisions, the resident was asked if he/she want to formulate an AD. The SSD stated if the resident does not have the capacity to understand and make medical decisions, the Resident's responsible party was asked if he/she want to formulate an AD. The SSD stated the copies of the POLST and AD with the resident's wishes and preferences in care should be in the resident's medical record. Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for two of eight sampled residents (Residents 185 and 19) by failing to ensure Advance Directive Acknowledge (ADA) Forms were completed on admission for Residents 19 and 185. These failures had the potential risk for facility staff to provide medical treatment and services against the will of Residents 19 and 185. Findings: a. During a review of Resident 185's admission Record (AR), the AR indicated the facility admitted Resident 185 on 1/15/2025, with diagnoses that included hypertension (high blood pressure) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). 056228 Page 2 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 185's Minimum Data Set (MDS, a resident assessment and screening tool), dated 1/20/2025, the MDS indicated Resident 185 had clear speech, understood others, and made self-understood. Resident 185 required partial/moderate assistance (helper dose less than half the effort) for upper body dressing and chair/bed-to-chair transfer. During a review of Resident 185's medical record on 1/21/2024 at 3:44 pm, Resident 185's medical record indicated, there was no AD or ADA available for review. During a concurrent interview with the Social Service Director (SSD), the SSD stated, there was no ADA form in Resident 185's medical record. The SSD stated, completing the ADA form was part of SSD assessment upon resident's admission. The SSD stated, the ADA form should be completed and placed in Resident 185's medical record so nursing staff would know resident's treatment wishes in case of an emergency. The SSD stated, This was resident's right. During an interview on1/21/2025 at 3:58 pm, Licensed Vocational Nurse 2 (LVN 2) stated, LVN 2 could not find a documentation regarding Resident 185's treatment wishes in Resident 185' medical record. LVN 2 stated, without the ADA, staffs would not know Resident 185's medical treatment choices during medical emergency and might treat residents against Resident 185's will. LVN 2 stated, the facility should follow the residents' treatment wished and that was resident's right. During a review of the facility's P&P titled, Advance Directives, dated 2/9/2024, the P&P indicated Upon admission, the admission staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 056228 Page 3 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment for two of two resident shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]). These deficient practices had the potential to expose residents to mold and injury from broken tile and cracked grout when receiving care in Shower rooms [ROOM NUMBERS]. Findings: During an observation on 1/22/25 at 2:30 p.m. in Resident Shower room [ROOM NUMBER], along the corners where the tile wall meets the tile floor, there were multiple areas of a black color substance on grout lines. The other areas of the shower room had cracked/missing/unsealed grout lines and cracked/broken and missing tiles. During a concurrent observation and interview on 1/23/25 at 10:30 a.m. with Housekeeping Staff 1 (HK 1), in Resident Shower room [ROOM NUMBER], HK 1 stated Housekeeping cleans the resident showers. HK 1 stated the shower is not clean and HK 1 reports any broken or repair work for the shower to the Maintenance Department. HK 1 stated she did not remember when she reported the condition of the shower to Maintenance [Department]. During a concurrent observation and interview on 1/23/25 at 10:35 a.m. with Housekeeping Staff 1 (HK 1), in Resident Shower room [ROOM NUMBER], HK 1 stated she was responsible for cleaning the shower room. HK 1 stated there is a maintenance logbook at Nursing Station 1 to report items that need repair, and HK 1 also verbally tells the Maintenance [Department] about the repair issue. During an observation of Shower room [ROOM NUMBER] with HK 1, a dark substance and cracked grout in the back, left corner of the shower room from where the floor meets the wall to 6 inches up the wall was observed. There was cracked grout and eroded tile in the back, right corner of the shower room. In addition, on the left side of the door trim was chipped paint and cracked grout, and on the right side of the door trim was cracked and missing wood and cracked grout lines. HK 1 stated the dark substance and repair work needed was reported 10 to 15 days ago to the Maintenance Department, but HK 1 could not remember the exact date. HK 1 stated the shower room condition poses a health and safety hazard to residents and could cause breathing problems for the residents. During a concurrent observation and interview on 1/23/25 at 10:43 a.m. with the Maintenance Supervisor (MS), in Resident Shower room [ROOM NUMBER], the MS stated Housekeeping is responsible to clean the showers. The MS stated maintenance is responsible to fix: 1) The escutcheon plate around the top shower handle with the plate not covering the hole in the tile. 2) The second escutcheon plate around the middle shower handle does not cover the broken tile near the handle. The MS stated both needed repairs and staff did not report it to the Maintenance Department. The MS stated the condition of the Shower room [ROOM NUMBER] is dirty and poses a health risk to the 056228 Page 4 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents. The MS stated he has a report of what he fixes and reports to the facility's QAPI (Quality Assurance Performance Improvement) Committee. During a review of the Maintenance Department's QAPI Report for October, November and December 2024, the report did not indicate that the Maintenance Department made any repairs to Resident Shower room [ROOM NUMBER] and Resident Shower room [ROOM NUMBER]. During a review of the Maintenance Department's Station 1, 2 and 3 logbooks for 2024, the logbooks indicated there were no entries for any requests for repairs for painting, cracked door trim, broken/cracked tiles, cracked grout or escutcheon repositioning/re-caulking for Resident Shower room [ROOM NUMBER] and Resident Shower room [ROOM NUMBER]. During a review of the facility's memo, dated 6/10/09 in Station 3 logbook, the memo was addressed to all supervisors and indicated, Please be informed that there's a new maintenance request log. All repairs needed should be documented accordingly and depending upon urgency should be repaired appropriately and timely. Maintenance Supervisor will check the log on a daily basis, signed and dated upon completion. For any urgent attention, he should be told verbally and in writing for quick action. During a review of the facility's policy and procedure (P&P) titled, West Haven Healthcare Center, undated, the P&P indicated, Policy: It is the policy of this facility to maintain in good repair at all times, all interior surfaces, fixtures, emergency and fire systems, equipment, appliances and furnishings to provide a safe, clean and comfortable environment for our patients. Procedures: Bathroom Fixtures and Bathroom Surfaces: a) Check grab bars and all protective guards and devices in toilets, bathrooms and showers regularly; d) Maintain plumbing fixtures in safe and good operating condition; e) Replace all cracked or broken tiles. Recalk as necessary around tile, bath fixtures, showers, tubs, etc. Apply new grout around tile as necessary; 7) Painting: a) The Housekeeping Supervisor keeps a list of rooms and surfaces that needs painting; b) Refer to the list when planning painting schedule. During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, revised 2/9/24, the P&P indicated, Policy: The facility provides residents with a safe, clean, comfortable and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. During a review of the facility's P&P titled, Housekeeping - General, revised 2/9/24, the P&P indicated: Purpose: To ensure that the facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors. All rooms of the facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents. The facility takes maximum precautions to protect against the spread of infectious diseases in the facility. Procedure: General Procedures: a) The Housekeeping Department is responsible for completing the daily, weekly, and monthly cleaning procedures; c) The Housekeeping Staff's general duties are to: Clean all surfaces in restrooms, showers, and utility rooms; Cleaning, Sanitizing, Disinfecting and 056228 Page 5 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0584 Sterilizing; In this facility, cleaning always means to clean and disinfect. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Maintenance Services, revised 2/9/24, the P&P indicated Purpose: To protect the health and safety of residents, visitors, and facility staff. Procedure: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include but are not limited to a) Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; b) Maintaining the building free from hazards; g) Establishing priorities in providing repair service; k) Providing routinely scheduled maintenance service to all areas; and l) Other services that may become necessary or appropriate. Residents Affected - Some 056228 Page 6 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 complete and transmit the quarterly Minimum Data Set (MDS - a resident assessment tool) in a timely manner for three of three sampled residents (Resident 13, federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. Residents Affected - Some a. For Resident 13, the quarterly MDS was not transmitted within 14 days after the quarterly assessment. b. For Resident 44, the MDS was not transmitted within 14 days after the quarterly assessment. c. For Resident 50, the MDS was not transmitted within 14 days after being admitted to the facility. These deficient practices resulted to a late completion and transmission of MDS assessment to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system and had the potential to affect the facility's quality monitoring data. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (congenital disorder of movement, muscle tone, or posture), rheumatoid arthritis (chronic inflammatory disease affecting hand & feet joints). During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13's cognition (ability to understand and process information) was intact. The MDS indicated Resident 13 was dependent (helper does all the effort) on staff for lower body dressing and toilet hygiene. Resident 13's previous MDS assessment was for dated from 8/5/2024 to 11/1/2024. b. During a review of Resident 44's AR, the AR indicated Resident 44 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (lung diseases blocking airflow and make it difficult to breathe) and hypertensive heart disease (complications of high blood pressure). During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44's was severely cognitively impaired. The MDS indicated Resident 44 needed partial/moderate assistance (helper does more than half the effort) with upper and lower body dressing, personal hygiene, and bed mobility (roll left and right, side to lying, and lying to sitting on side of bed). Resident 44's previous MDS assessment was for dated from 8/2/2024 to 11/4/2024. c. During a review of Resident 50's AR, the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure (heart doesn't pump blood as well as it should), acute respiratory(respiratory system can't maintain normal levels of oxygen and carbon dioxide). 056228 Page 7 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 was severely cognitively impaired. The MDS indicated Resident 50 required substantial/maximal assistance with upper and lower body dressing and was dependent on staff for rolling left and right. Resident 50's previous MDS assessment was for dated from 8/29/2024 to 11/8/2024. During an interview on 1/23/2025, at 2:02 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated the MDS assessment was done upon resident admission, quarterly, annually, and whenever the resident had a Change of Condition (COC) or discharged from the facility. The MDSC stated the time frame for completing the MDS assessment was 14 days from the Assessment Reference Date (ARD) and no more than 92 days from last MDS assessment. The MDSC stated the MDS assessment was part of the CMS requirement with Medicare & Medicaid. The MDSC stated that these three residents' (Residents 13, 44 and 50's) MDS assessments were the assessment that the MDSC sent but could be not transmitted to CMS. During a record review of the CMS Submission Report, dated 1/23/25, the CMS Submission Report indicated the record for Resident 13, Resident 44, and Resident 50 was submitted late. During a record review of the facility's Policy & Procedure titled, RAI Process, dated February 2024, indicated The facility will transmit MDS assessments in accordance with the transmission dates Required Assessment Summary Medicare Assessment Reporting Schedule. The Required Assessment Summary 056228 Page 8 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 one (1) of two (2) sampled residents (Resident 41) received treatment and care in accordance with the physician's order for the administration of Chlorpromazine/Risperidone (antipsychotic medications) by failing to ensure Resident 41 was monitored for orthostatic hypotension with two blood pressure readings 5 to 10 mins apart and observed for adverse side effects. Residents Affected - Some This deficient practice had the potential to cause Resident 41's blood pressure to decrease ( hypotension, blood pressure that is too low) with dizziness and fainting that could lead to falls and injuries. Findings: During a review of Resident 41's admission Record (AR), the AR indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (a brain disorder that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), muscle weakness (decreased strength of the muscles), and other abnormalities of gait and mobility (any deviations from normal walking or gait). During a review of Resident 41's History and Physical (H&P), dated 1/29/24, the H&P indicated, Resident 41 had the capacity to understand and make decisions. During a review of Resident's 41's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/23/24, the MDS indicated, Resident 41 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 41 required set up or clean up assistance with eating, required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. The MDS also indicated Resident 41 required substantial/maximal assistance with shower/bathe self, and was dependent for toileting hygiene, lower body dressing and putting on/taking off footwear. During a review of Resident 41's Fall Risk (Morse) Assessments (method of assessing a patient's likelihood of falling; score scale: low risk = 0-24, moderate risk = 25-44, high risk = 45 and higher), dated 7/23/24, 10/22/24 and 1/24/25, the assessments indicated Resident 41 was evaluated as a high risk with a score of 55 (due to history of falls, secondary diagnosis, and mental status). During a review of Resident 41's Physician Order Summary Reports for active orders as of 12/1/24 and 1/24/25, the reports indicated a Chlorpromazine/Risperidone monitor order (antipsychotic): Monitor orthostatic hypotension, take BP [blood pressure] supine [lying horizontally with the face and torso facing up], wait 5-10 minutes then sitting position. Call MD if there is 20mmHg [millimeters of mercury] and drop in SBP [systolic blood pressure] or a drop of 10 mmHg in DBP [diastolic blood pressure] between the two readings. Report to MD if adverse side effects is/are observed; every 7 day(s). The reports indicated the order date was 1/21/24 and the method of communication was by phone. During a review of Resident 41's Care Plan titled, At Risk for Side Effects of Risperidone, Chlorpromazine, initiated on 2/5/24, indicated Resident 41 will remain free of psychotropic drug related complications including hypotension. The care plan interventions included Chlorpromazine/Risperidone 056228 Page 9 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some monitor order (antipsychotic): Monitor orthostatic hypotension, take BP supine, wait 5-10 minutes then sitting position. Call MD if there is 20mmHg and drop in SBP or a drop of 10 mmHg in DBP between the two readings. Report to MD if adverse side effects is/are observed; every 7 day(s). During a review of Resident 41's Medication Administration (MAR) for the months of December 2024 and January 2025, the MAR indicated for 12/1/24 - 12/31/24, blood pressure (BP) readings for the Chlorpromazine/Risperidone (antipsychotic) monitor order were only taken one time at 9 a.m. and 5 p.m. and not 5-10 minutes apart as per physician order. The readings were as follows: 12/1/24 at 9 a.m. - BP 112/73 12/1/24 at 5 p.m. - BP 120/72 12/8/24 at 9 a.m. - BP 120/75 12/8/24 at 5 p.m. - BP 118/73 12/15/24 at 9 a.m. - BP 121/67 12/15/24 at 5 p.m. - BP 122/69 12/22/24 at 9 a.m. - BP 120/71 12/22/24 at 5 p.m. - BP 124/75 12/29/24 at 9 a.m. - BP 122/80 12/29/24 at 5 p.m. - BP 125/76 For the period between 1/1/25 -1/24/25, the MAR indicated blood pressure (BP) readings for the Chlorpromazine/Risperidone (antipsychotic) monitor order were only taken one time at 9 a.m. and 5 p.m. and not 5-10 minutes apart as per physician order. The readings were as follows: 1/5/25 at 9 a.m. - BP 122/72 1/5/25 at 5 p.m. - BP 123/72 1/12/25 at 9 a.m. - BP 119/79 1/12/25 at 5 p.m. - BP 126/81 1/19/25 at 9 a.m. - BP 122/66 1/19/25 at 5 p.m. - BP 125/68 During a review of Resident 41's Weights and Vitals Summary for the month of December 2024, the summary indicated no second sitting position blood pressure (BP) readings were taken as per physician order. The BP readings were as follows: 056228 Page 10 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0684 12/1/24 at 12:59 a.m. - BP 118/75 (lying, right arm) Level of Harm - Minimal harm or potential for actual harm 12/1/24 at 9:18 a.m. - BP 112/73 (lying, left arm) 12/1/24 at 4:33 p.m. - BP 120/72 (lying, left arm) Residents Affected - Some 12/8/24 at 1:39 a.m. - BP 128/76 (lying, right arm) 12/8/24 at 9:12 a.m. - BP 120/75 (lying, right arm) 12/8/24 at 7:57 p.m. - BP 118/73 (lying, left arm) 12/15/24 at 1:52 a.m. - BP 120/70 (lying, right arm) 12/15/24 at 9:15 a.m. - BP 121/67 (lying, right arm) 12/15/24 at 8:35 p.m. - BP 122/69 (lying, left arm) 12/22/24 at 2:27 a.m. - BP 113/68 (lying, left arm) 12/22/24 at 9:23 a.m. - BP 120/71 (lying, left arm) 12/22/24 at 5:16 p.m. - BP 124/75 (lying, left arm) 12/29/24 at 9 a.m. - BP 122/80 (lying, left arm) 12/29/24 at 4:26 p.m. - BP 125/76 (lying, right arm) During a review of Resident 41's Weights and Vitals Summary for the period between 1/1/25 -1/24/25, the summary indicated only one sitting position blood pressure (BP) reading taken, but not within 5-10 minutes of the lying blood pressure reading as per physician order. The BP readings were as follows: 1/5/25 at 1:55 a.m. - BP 128/76 (lying, right arm) 1/5/25 at 9:47 a.m. - BP 122/72 (lying, left arm) 1/5/25 at 10:43 a.m. - BP 119/75 (lying, left arm) 1/5/25 at 5:33 p.m. - BP 123/72 (lying, left arm) 1/12/25 at 2:38 a.m. - BP 125/82 (lying, right arm) 1/12/25 at 9:43 a.m. - BP 119/79 (lying, left arm) 1/12/25 at 5:23 p.m. - BP 126/81 (lying, left arm) 1/12/25 at 6:51 p.m. - BP 129/77 (lying, left arm) 056228 Page 11 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0684 1/19/25 at 1:56 a.m. - BP 124/65 (lying, left arm) Level of Harm - Minimal harm or potential for actual harm 1/19/25 at 7:36 a.m. - BP 122/66 (sitting, left arm) 1/19/25 at 5:36 p.m. - BP 125/68 (lying, left arm) Residents Affected - Some During a concurrent interview and record review on 1/24/25 at 9:55 a.m. with Licensed Vocational Nurse 3 (LVN 3), the Medication Administration Record (MAR) for Resident 41, dated January 2025 was reviewed. The MAR indicated, Chlorpromazine/Risperidone monitor order (antipsychotic): Monitor orthostatic hypotension, take BP supine, wait 5-10 minutes then sitting position. Call MD if there is 20mmHg and drop in SBP or a drop of 10 mmHg in DBP between the two readings. Report to MD if adverse side effects is/are observed; every 7 day(s). LVN 3 acknowledged there was only 1 BP reading at 9 a.m. and that there should be a second time for a blood pressure reading in the sitting position. LVN 3 acknowledged there was only 1 BP reading at 5 p.m. and that there should be a second time for a blood pressure reading in the sitting position. LVN 3 stated it is important to take both readings each time because the drop in blood pressure could affect the resident where she may faint or fall and sustained an injury. LVN 3 stated Resident 41 is a high risk for falls. During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, effective date, 10/2017, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. The P&P further indicated, Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician orders are checked for the correct dosage schedule .Administration: Medications are administered in accordance with written orders of the attending physician. During a review of the P&P titled, Physician Orders, date implemented, 2/9/2024, the P&P indicated, Purpose: This will ensure that all physician orders are complete and accurate. The P&P further indicated, Treatment orders will include the following: 1) A description of the treatment, including the treatment site, if applicable; 2) The frequency of treatment and duration of order (when appropriate); and 3) The condition/diagnosis for which the treatment is ordered. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR binders. During a review of the facility's P&P titled, Fall Management Program, revised 11/2024, the P&P indicated, Policy: It is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The Facility has developed a Fall Management Program that strives to prevent and reduce the risk of resident falls through meaningful assessments, interventions, education, and reevaluation. 056228 Page 12 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed ensure the bed grab bar foam pads for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precaution was in good condition for one of two sampled residents (Resident 9). This failure had the potential to put Resident 9 at risk for injury. Findings: During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 1/7/2020, with diagnoses that included epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures-involuntary movement) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment and screening tool)), dated 12/25/2024, indicated Resident 9 had clear speech, understood others, and made self-understood. Resident 9 required partial/moderate assistance (helper dose less than half the effort) for upper body dressing and chair/bed-to-chair transfer. During an observation on 1/21/2025 at 9:56 am, in Resident 9's room, Resident 9's grab bars at both side of Resident 9's bed were padded with foams. The bed grab bar foam pads were ripped and teared with metal bars exposed. During a review of Resident 9's Order Summary Report (OSR), dated 1/22/2025, the OSR indicated there was an order dated 2/11/2020 to transfer the grab bars to both sides of bed for bed mobility. The OSR indicated for staff to monitor placement and function every shift. The OSR indicated Resident 9 was on Keppra, 500 milligrams (medication to treat epilepticus) by mouth two times a day, and being monitored every shift for episodes of seizure activity. During a review of Resident 9's plan of care (CP), dated 1/11/2024, the CP indicated Resident 9 was at high risk for trauma/injury/falls related to seizure disorder. The interventions including to keep environment free of safety hazards and monitor the side rails and positioning for possible injuries. During an interview on 1/22/2025 at 2:33 pm, Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, the foams that wrapped around the grab bars on Resident 9's bed were all broken, teared open and exposed the inside metal part. LVN 2 stated, Resident 9 was on seizure medication and being monitored for seizure activities. LVN 2 stated, the padded foams were the precaution to avoid injury when Resident 9 experienced seizure activities, so Resident 9 would not bump Resident 9's body parts to the metal bars causing injuries. LVN 2 stated, the facility should make Resident 9's surrounding environment free from hazards. LVN 2 stated, This is a resident safety issue. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated 7/2024, indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. These risk factors and environmental hazards include bed safety. 056228 Page 13 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0692 Provide enough food/fluids to maintain a resident's health. 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 provide set-up assistance (helper sets up, resident completes the activity) during lunch time for one of one sampled resident (Resident 15). Residents Affected - Few This failure had the potential for Resident 15 to lose weight due to decrease meals/fluid intake, dehydration and electrolyte imbalance. Findings: During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), hyperlipidemia (elevated level of lipids like cholesterol and triglycerides), and chronic kidney disease (presence of kidney damage or decreased kidney function). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, the MDS indicated, Resident 15 had severely impaired cognition (ability to understand). The MDS indicated Resident 15 required set up or clean-up assistance with eating, substantial/maximal assistance (helper did more than half the effort) with oral hygiene and upper body dressing and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with toileting, shower lower body dressing and personal hygiene. During a review of Resident 15's Care Plan (CP), dated 1/10/2025, the CP indicated Resident 15 was at risk for dehydration, malnutrition, and weight loss. The interventions included to assist at mealtime and for all food or fluid offerings, provide for cueing and prompting and to monitor every meal and to assess eating pattern. During an observation and a concurrent interview with Resident 15 on 1/21/2025 at 12:12 pm inside Resident 15's room, Resident 15 was lying in bed, on her back with bed on its lowest position. Resident 15's food tray was on the overbed table. Overbed table was high, and away from the resident. Resident 15 stated she could not reach the table. During a concurrent observation and interview on 1/21/2025 at 12:31 pm with Licensed Vocational Nurse 1 (LVN 1), inside Resident 15's room, the food was still on the overbed table. Overbed table was still high and away from the resident. LVN 1 stated Resident 15 could eat by herself but needed food tray to be set up in front of the resident. LVN 1 stated Resident 15 could not reach the tray and could not stand up. LVN 1 stated the food tray should have been set up when staff delivered the food tray for Resident 15 to enjoy the food while the food was warm. During an interview on 1/23/2025 at 3:50 pm with the Director of Nursing (DON), the DON stated, resident should sit up and food tray should be set up and opened in front of the resident so the resident could eat while food was warm and palatable. The DON stated letting the food tray on the table for a long time change its taste and might affect the resident's appetite which could lead to weight loss. During a review of the facility's policy and procedure titled, Assisting Resident with In-Room Meals, revised 7/2024, the P&P indicated, The resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is 056228 Page 14 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0692 Level of Harm - Minimal harm or potential for actual harm served his or her meal in bed, use wedges and pillows to achieve a nearly upright position. Place the tray on the overbed table or serving area. Be sure it is adjusted to a comfortable position and height for the resident. Arrange the dishes and silverware so that they can be easily reached by the resident. Once you are certain that you have given the resident adequate assistance, exited the room and allowed the resident to eat his or her meal. Residents Affected - Few 056228 Page 15 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 234). This failure had the potential for complications related to tube feeding for Resident 234. Findings: During a review of Resident 234's admission Record (AR), the AR indicated, Resident 234 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common foe people with swallowing problems). During a review of Resident 234's Order Summary Report (OSR), dated 12/25/2024, the OSR indicated, Resident 234 had an order for GT site treatment to cleanse with normal saline (NS, a saltwater solution), pat dry, apply calcium alginate (absorbent, non-adherent wound dressing), split gauze dressing (a pre-cut gauze pad with a slit that allows it to fit snugly around tubes and drains) and secure with paper tape daily and as needed if dressing was soiled or dislodged. During a review of Resident 234's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS indicated, Resident 234 had severely impaired cognition (ability to understand). The MDS indicated Resident 234 required partial/moderate assistance (helper did less than half of the effort) with oral hygiene and upper body dressing, substantial/maximal assistance (helper did more than half the effort) with personal hygiene and dependent (helper did all the effort, resident did none of the effort to complete the activity) with toileting, shower and lower body dressing. The MDS indicated Resident 234 required feeding tube for nutrition. During a review of Resident 234's Care Plan (CP), dated 1/6/2025, the CP indicated, Resident 234 was at risk for skin irritation and infection related to the gastrostomy site. The CP interventions included to inspect the skin around the gastrostomy site for presence of irritation, redness, swelling, discharges/drainage, pain or excess skin growing around the tubes at least daily, to monitor for bleeding, monitor for stomach leakage around the tube and to provide treatment as ordered. During a concurrent observation and interview on 1/21/2025 at 10:02 am with Registered Nurse Supervisor (RN) inside Resident 234's room, Resident 234 was in bed, on his back, and had a GT site with no dressing and bloody drainage around the GT site. RN stated the GT site was not clean. During an interview on 1/21/025 at 10:25 am with the Treatment Nurse (TN), the TN stated GT site dressing changes should be done daily and as needed when soiled and dislodged to maintain skin integrity, for wound healing and to prevent infection around the GT site. During an interview on 1/23/2025 at 4:05 pm with the Director of Nursing (DON), the DON stated, GT site should be clean and covered with a dressing as ordered by the physician to contain any drainage and to prevent skin irritation and infection around the site. 056228 Page 16 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0693 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Feeding Tube-Site Care, dated 2/9/2024, the P&P indicated, The site of a well-established enteral feeding tube will be inspected daily for signs and symptoms of irritation, gastric leakage, or irritation. Place a gauze drainage sponge around the site if needed for irritation, drainage, or leakage. Residents Affected - Few 056228 Page 17 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of grab bars (bars installed on the side of the bed)/bed rails/side rails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 237) by failing to: a. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 237 before the installation of grab bars. b. Ensure to obtain an informed consent to review the risks and benefits before the installation of grab bars. c. Ensure to develop an individualized person-centered care plan on the use of grab bars to meet the resident's specific needs. These failures placed Resident 237 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed), and injury from the use of grab bars. Findings: During a review of Resident 237's admission Records (AR), the AR indicated, Resident 237 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and muscle weakness (lack of muscle strength). During a review of Resident 237's Minimum data Set (MDS, a resident assessment tool), dated 1/19/2025, the MDS indicated, Resident 237 had an intact cognition (ability to understand). During a concurrent observation and interview on 1/21/2025 at 10:42 am with Registered Nurse Supervisor (RN) inside Resident 237's room, Resident 237 was lying in bed on her back with grab bars up on both sides of the bed. Resident 237's bed was in a high position. The RN stated the grab bars were used as enabler for Resident 237's bed mobility. The RN stated Resident 237 was alert and coherent. During a concurrent interview and record review on 1/22/025 at 3 pm with Minimum data Set Coordinator (MDSC), Resident 237's medical records (chart) and PointClickCare (PCC, a cloud-based software used in long-term and post-acute care facilities) were reviewed. The MDSC stated, there were no documented evidence that appropriate alternative interventions were attempted and did not meet the needs of Resident 237 before grab bars were installed, no informed consent was obtained before grab bars were installed and care plan was not developed after grab bars were installed. The MDSC stated appropriate alternative interventions should be attempted before grab bars were installed for the safety of the resident. The MDSC stated Resident 237 should be consented to make sure that the resident understood and educated on the risks and benefits of using grab bars and care plan should be created to ensure staff would provide the proper interventions specific for Resident 237. During an interview on 1/23/2024 at 3:43 pm with the Director of Nursing (DON), the DON stated, the least restrictive, appropriate alternative interventions should be attempted first and did not meet 056228 Page 18 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the needs of the resident before grab bars would be installed because of its potential for entrapment and injury to the resident. The DON stated the use of grab bars should be consented first before its installation to make sure that risks and benefits of using grab bars were explained to the resident and understood. The DON stated the used of the grab bars should be care planned to communicate among staff regarding the interventions specific for the resident. The DON stated the grab bars, bed rails and side rails belong to the same category. During a review of the facility's P&P titled, Bed Rails, dated 2/9/2024, the P&P indicated, The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavior patterns for which bed a bed rail was considered. If a bed rail is used as an enabler, the resident/resident representative's informed consent will be obtained by a licensed nurse or the physician. The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs will be met during the use of bed rails. 056228 Page 19 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

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. Based on interview and record review, the facility failed to attempt a gradual dose reduction for one of 5 sampled residents (Resident 11). This deficient practice put Resident 11 at risk of receiving unnecessary medication. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 5/5/2009 and readmitted Resident 11 on 12/13/2024 with diagnoses that included cellulitis (bacterial skin infection), sepsis (a life-threatening complication of an infection), and major depressive disorder (persistent feelings of sadness, loss of interest that interfere with daily life). During a record review of Resident 19's Physician Orders (PO), dated 2/13/2024, the PO indicated Lexapro (Escitalopram Oxalate, medication used to treat depression), oral Tablet 5 milligrams (mg) give one tablet by mouth one time a day related to major depressive disorder, recurrent, manifested by (m/b) persistent crying related (r/t) unable to do things she used to do. During a review of Resident 11's monthly Medication Regimen Review (MRR), dated 8/21/2024, indicated Resident 11 had been taking Lexapro 5 mg since 2/13/24 and a GDR was recommended. During a review of Resident 11's Medication Administration Record (MAR), dated from 9/1/2024 to 11/30/2024, the MAR indicated there was no depressive behavior documented for Resident 11. During a review of Resident 11's Psychiatric Notes (PN), dated 10/19/2024, the PN indicated Risk Assessment for Resident 11 was overall low risk at this time. A review of Resident 11's Minimum Data Set (MDS- a resident assessment and care screening tool), dated 12/17/24, indicated Resident 11 was cognitively intact (ability to think and understand). The MDS indicated Resident 11 was dependent for upper and lower body dressing, toileting hygiene, and roll left to right. During a review of Resident 11's History & Physical (H&P), dated 12/18/2024, the H&P indicated Resident 11 had the capacity to understand and make decisions. During review of Resident 11's MAR, dated from 1/1/2025 to 1/31/2025, the MAR indicated there was no depressive behavior documented for Resident 11 during the period of 1/1/2025 to 1/24/25. During an interview on 1/24/25, at 12:10 p.m., with the Director of Nursing (DON), the DON stated there had been no GDR attempted for Lexapro 5 mg from 2/13/2024 to 1/24/2025 for Resident 11. The DON stated, We monitored/assessed the resident's behavior and completed the GDR base on the resident's behavior. The DON stated, It looks like the GDR was overlooked due to hospital transfers for Resident 11. The DON stated it was important to complete a GDR for Resident 11 to reduce the medication side effects of Lexapro. During a record review of the facility's Policy & Procedure titled, Psychotherapeutic Drug 056228 Page 20 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0758 Level of Harm - Minimal harm or potential for actual harm Management, date revised May 2024, indicated The Attending Physician will review the current drug regimen monthly and determine if the resident should remain on the same dose or an adjustment should be made. Unless clinically contraindicated, the Attending Physician will attempt a Gradual Dose Reduction (GDR). Residents Affected - Few 056228 Page 21 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in accordance with the facility's Policy and Procedure (P&P) for two of two boxes of potato (hash browns). Residents Affected - Some This failure had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 1/21/2025 at 9:42 am with the Dietary Supervisor (DS) inside the dry food storage area of the facility's kitchen, there were two boxes of unopened, dehydrated, and seasoned potato (hash browns) with received date of 11/19/2024 and used by date of 1/19/2025. The DS stated food products needed to be use before the used by date to make sure food served to the residents were safe and of good quality. During an interview on 1/23/2025 at 4:17 pm with the Director of Nursing (DON), the DON stated, food items that had a used by date should be use within the specified used by date to make sure that food served were at its highest quality and to prevent food-borne illnesses. During a review of the undated list of dry goods storage guidelines, the list indicated unopened potato on shelf had a storage length of 2 months. During a review of the facility's undated P&P titled, Storage of Food and Supplies, the P&P indicated, Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated-month, date, year. All food products will be used per the times specified in the Dry Food Storage Guidelines. The storage times in the guidelines are intended to be on the safe side. 056228 Page 22 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. 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 its binding arbitration agreements included a selection of a neutral arbitrator and a venue convenient to both the facility and resident/resident responsible party for two of four sampled residents (Residents 15 and 65). Residents Affected - Some These failures placed Residents 15 and 65 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA, stroke, loss of blood flow to a part of the brain), dementia (a progressive state of decline in mental illness) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, the MDS indicated, Resident 15 had severely impaired cognition (ability to understand). The MDS indicated Resident 15 required substantial/maximal assistance (helper did more than half the effort) with oral hygiene and upper body dressing and dependent (helper did all the effort, resident did none of the effort to complete the activity) with toileting, shower lower body dressing and personal hygiene. During a concurrent interview and record review on 1/24/2025 at 12:18 pm with the admission Coordinator (AC), Resident 15's Arbitration Agreement (AA), dated 8/29/2023 was reviewed. The AC stated, the AA form indicated, Resident 15's responsible party signed the arbitration agreement. The signed AA did not include information regarding the selection of a neutral arbitrator and a venue convenient to both the facility and the resident or the resident's responsible party. The AC stated Resident 15 had the old version of the AA form. The AC stated Resident 15, or Resident 15's responsible party should have given the updated/revised AA form. The AC stated, It's the resident's rights to be informed. b. During a review of Resident 65's admission Record (AR), the AR indicated, Resident 65 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening blood infection), dementia (a progressive state of decline in mental illness), dysphagia (difficulty swallowing) and epilepsy (a brain disorder that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells). During a review of Resident 65's MDS, dated [DATE], the MDS indicated, Resident 65 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 65 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing and personal hygiene. During a concurrent interview and record review on 1/24/2025, at 12:18 pm with the AC, Resident 65's AA, dated 10/10/23 was reviewed. The AC stated, the AA form indicated, Resident 65's responsible party signed the agreement. The signed AA did not include information regarding the selection of a neutral arbitrator and a venue convenient to both the facility and the resident or the resident's responsible party. The AC stated Resident 65 had the old version of the AA form. The AA form indicated 056228 Page 23 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0848 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 65, or her responsible party should have given the updated or revised form of AA because it was part of the resident's rights to be informed. During a review of the facility's Policy and Procedure (P&P) titled, Arbitration Agreement, dated 2/9/2024, the P&P indicated, The Administrator, or designee, will ensure use of the latest revision of the Arbitration Agreement that complies with all the applicable federal and state laws. To the extent than an existing Arbitration Agreement executed between the facility and a resident is subsequently deemed unenforceable under applicable law, the Facility may seek to enter into a newer enforceable version of the Arbitration Agreement. 056228 Page 24 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow infection prevention guidelines for an Enhanced Barrier Precaution room (EBP, infection control measure that involve wearing gloves and gowns during high contact patient care to prevent the spread of bacteria) for one of one sampled resident (Resident 78) when the private care giver (PC) was inside Resident 78's room helping other staff member giving Resident 78 a bed bath without wearing a gown. Residents Affected - Few This failure had the potential to result in spreading infections from Residents 78 to the PC, staff members and other residents in the facility. Findings: During a review of Resident 78's admission Record (AR), the AC indicated the facility admitted Resident 78 on 12/24/2024, with diagnoses that included hypertension (high blood pressure) and pressure Ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible). During a review of Resident 78's Minimum Data Set (MDS, a resident assessment and screening tool), dated 12/28/2024, the MDS indicated Resident 78 had clear speech, usually understood others, and usually made self-understood. The MDS indicated Resident 78 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene and chair/bed-to-chair transfer. During an observation on 1/21/2025 at 10:41 am, outside Resident 78's room, there was a signage posted at the door indicated Resident 78 was on EBP. Resident 78's PC was inside Resident 78's room assisting a staff member providing a bed bath to Resident 78. The PC did not wear a gown when the PC was in close contact with Resident 78. During a concurrent interview, Resident 78's PC stated, the PC did not wear a gown when assisting staff performing bed bath for Resident 78. The PC stated, EBP measure was to prevent Resident 78 from cross infections. The PC stated the measure was to protect both resident and care givers. During an interview on 1/21/2025 at 11:01 am, Infection Preventionist Nurse (IPN), the IPN stated, Resident 78 was on EBP due to stage 2 pressure ulcer wound and the PC should wear a gown when providing care and in close contact care including bed bath. The IPN stated, This was to prevent cross contaminations and protect both residents and care givers from infection. During a review of Resident 78's Order Summary Report (OSR), dated 1/22/2025, the OSR indicated the physician ordered EBP for Resident 78 due to pressure ulcer. During a review of the facility's policy and procedure (P&P) titled, Standard and Enhanced Precautions, dated 4/1/2024, the P&P indicated for residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: dressing, bathing and showering . 056228 Page 25 of 26 056228 01/24/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 19). This failure had the potential to affect Resident's 19 quality of life and overall health. Findings: During a review of Resident 19's admission Record (AR), the AR indicated, Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and myocardial infarction (heart attack). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 11/29/2024, the MDS indicated, Resident 19 had an intact cognition (ability to understand). The MDS indicated Resident 19 required partial/moderate assistance (helper did less than half the effort) with oral hygiene and dependent (helper did all the effort, resident did none of the effort to complete the activity) with toileting, shower and personal hygiene. During a concurrent observation and interview on 1/21/2025 at 10:52 am with the Registered Nurse Supervisor (RN) inside Resident 19's room, Resident 19 had a standing white electric fan in the room. The electric fan blades were dirty and dusty. The RN stated the dirt and dust on the fan blades were not good and might cause allergy (an immune system overreaction to a normally harmless substance) to Resident 19. During an interview on 1/21/2025 at 11 am with the Maintenance Supervisor (MS), the MS stated, the dirt and dust might cause respiratory illnesses to the residents. During an interview on 1/23/2025 at 3:41 pm with the Director of Nursing (DON), the DON stated, housekeeping needed to clean and maintain any equipment inside the resident's room every day to prevent infection. The DON stated dirt and dust could be inhaled and cause respiratory-related diseases to the residents. During a review of the facility's policy and procedure titled, Housekeeping-General, dated 2/9/2024, the P&P indicated, The Housekeeping Department uses safe and proper methods for cleaning, disinfecting, and sterilizing all areas, surfaces, and equipment as required by law. All rooms of the facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents. 056228 Page 26 of 26