Health inspection·July 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement care plans (CP- a personalized document that outlines a resident's medical and social care needs and the actions required to address them) for four of seven sampled residents (Residents 1, 2, 6, and 7) according to the facility's policy and procedure (P&P) titled, Care Planning, by failing to: 1. Ensure Residents 1 and 6 had CPs developed for the administration of intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) antibiotics (abx- medication that inhibits the growth of or destroys bacteria in the body). 2. Ensure Resident 7 had a CP developed and implemented for the use of peripherally inserted central venous catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart). 3. Ensure Resident 2's CP for IV indicated the location of the IV. These failures resulted in Residents 1, 2, 6, and 7 not having an appropriate CP developed or implemented. These failures had the potential for Residents 1, 2, 6, and 7 to not receive the care and services needed for IV services and to treat the residents' medical conditions.Findings: a1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 was readmitted on [DATE] with diagnoses that included urinary tract infection (UTI- infection that happen when bacteria enter the urethra, and infect the urinary tract) acute kidney failure (when the kidneys suddenly stop working due to complication of another serious illness), and unspecified hydronephrosis (a condition where urine backs up into the kidneys, causing them to swell, generally caused by infection or obstruction). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had an active UTI. The MDS indicated Resident 1 was taking an abx. During a review of Resident 1's Order Summary Report (OSR) date range [DATE] to [DATE], the OSR indicated Resident 1 had an order for Cefepime HCl Intravenous Solution (type of abx), two grams (gm- unit of measurement) per 100 milliliters (mL- unit of measurement). The OSR indicated to give Resident 1 one dose daily intravenously every 12 hours for UTI for five days. The OSR indicated to start Cefepime on [DATE]. During a review of Resident 1's untitled Care Plan Report (CPR), the CPR did not indicate Resident 1 had a CP initiated for use of IV abx therapy, Cefepime. a2. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on [DATE] with diagnoses that included candidal sepsis (a severe bloodstream infection caused by Candida [type of fungus], which can lead to organ damage and even death), asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 6's OSR, date range from [DATE] to [DATE], the OSR indicated Resident 6 had an IV order for Caspofungin (an antifungal medication, used to treat Page 1 of 10 056228 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some serious fungal infections), 50 milligrams (mg- unit of measurement)) IV every 24 hours for 12 days for fungal infection to the upper right chest dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) catheter (line used for dialysis). The OSR indicated the order date was [DATE]. During a review of Resident 6's untitled CPR, the CPR did not indicate Resident 1 had a CP initiated for use of IV antifungal therapy, Caspofungin. During a review of Resident 6's MDS dated [DATE], the MDS indicated that Resident 6 had intact cognition. The MDS indicated Resident 6 was on IV medication and had IV access. b. During a review of Resident 7's AR, the AR indicated the facility admitted Resident 7 on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sepsis, bacteremia (bacterial infection in the bloodstream), and unspecified respiratory failure (serious condition that makes it breathe on one's own). During a review of Resident 7's OSR, date range from [DATE] to [DATE], the OSR indicated Resident 7 had an IV medication order for Zosyn (type of abx), four and a half (4.5) gm IV via PICC line, every eight hours for five days for sepsis. The order date was [DATE]. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. The MDS indicated Resident 7 had pneumonia (an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus) and was on abx. During a review of Resident 7's untitled CPR, the CPR did not indicate Resident 7 had a CP initiated for use of PICC. c. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on [DATE] and was readmitted on [DATE] with diagnoses that included sepsis due to Escherichia coli (E. coli- a type of bacteria commonly found in the intestines [gut] and urinary tract), UTI, and bacteremia. During a review of Resident 2's OSR, date range [DATE] to [DATE], the OSR indicated Resident 2 had an IV order for Meropenem (type of abx) one gm, every 12 hours for seven days for (treatment of) extended-spectrum beta-lactamase (ESBL- enzymes produced by certain bacteria that make them resistant to many beta-lactam antibiotics) E. coli bacteremia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. The MDS indicated Resident 2 had a UTI in the last 30 days and was on abx therapy. The MDS indicated Resident 2 had an IV upon admission for abx use. During a review of Resident 2's untitled CPR, the CPR indicated Resident 2 had a CP initiated on [DATE] for at risk for infection and complications related to PIV line. The CP did not indicate the location or site of the PIV. The CP goals indicated Resident 2 would be free form signs and symptoms of infection related to IV line through the review date. The CP goals indicated to check the IV site for patency (openness) and dislodgment (not in the vein), flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)] IV line with 10 mL of NS before and after IV medications and to flush IV line with 10 mL NS every 12 hours when IV is not in use. During a concurrent interview and record review on [DATE] at 10:19 am, with the MDS Coordinator (MDSC), Residents 1, 2, 6, and 7's CPRs were reviewed. The MDSC stated Resident 7 did not have a CP for (use of) PICC. The MDSC stated Resident 7 should have a CP for use of PICC because staff needed to know what interventions to follow regarding the use. The MDSC stated MDSC could not find the location of Resident 2's PIV in the CPR or in any of Resident 2's records. The MDSC stated Resident 2's CP for PIV needed to indicate the location of the PIV so staff would know where to monitor and assess for complications. The MDSC Residents 1 and 6's CPR did not include a CP for (use of) abx therapy. The MDSC stated all residents on abx therapy needed a CP initiated because residents on abx therapy for being monitored for complications and adverse side effects. During an interview on [DATE] at 2:13 pm, with the Director of Nursing (DON), the DON stated (in general) all residents on IV medications, such as abx, and the IV access needed to be incorporated into the residents' plan of care because there were supposed to be interventions in place to prevent 056228 Page 2 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some complications. The DON stated all IV CPs needed to indicate the site so staff know where to look and apply the interventions. The DON stated without CPs, the licensed nurses did not have a roadmap to the residents. During a review of the facility's P&P titled, Care Planning, implemented [DATE], the P&P indicated the purpose was to ensure that a comprehensive, person-centered CP was developed for each resident based on individual assessed needs. The P&P indicated the facility would develop a person-centered baseline CP for each resident within 48 hours of admission and would include at least the following information: physician orders, dietary services, therapy services, and social services. The P&P indicated once the baseline CP was completed, the facility must provide the resident and/or the resident's representative with a written summary of the baseline CP that included: initial goals of the resident, summary of medications and dietary instructions, services or treatments to be administered, and updated information on completion of the comprehensive CP, as indicated. 056228 Page 3 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide clear, complete and signed intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) medication orders, and IV flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) orders according to the facility's policies and procedures (P&P) titled, Medication Orders, Peripheral Catheter (IV) Flushing, and, Continuous Infusion of Medications and Solutions, for seven of seven sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7) by failing to: 1. Ensure Resident 1's Physician Order for Infusion (IV) Therapy (POFIT) dated 6/30/2025, and IV medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) dated 6/2025 to 7/2025 indicated peripheral (away from the heart) IV flush orders and that licensed nurses (LN) Resident 1's IV was being flushed with 10 milliliters (mL- unit of measurement) NS every 12 hours as indicated. 2. Ensure Resident 2's IV MAR dated 6/2025 indicated when to flush Resident 2's IV according to the POFIT, dated 6/19/2025, and that LNs were flushing Resident 2's IV with 10 mL NS every 12 hours as indicated in the POFIT. 3. Ensure Resident 3's LNs were flushing Resident 3's IV with 10 mL NS every 12 hours as indicated in Resident 3's IV MAR dated 7/2025 and ensure Resident 3's POFIT, dated 7/7/2025 was signed by the physician, indicated peripheral IV flush orders, and indicated an accurate dose of IV medication. 4. Ensure Resident 4's POFIT dated 7/7/2025 was signed by Resident 4's physician. 5. Ensure Resident 5's POFIT dated 5/9/2025 indicated the dose, frequency, and diagnosis for use of IV vancomycin (type of antibiotic [abxmedication that inhibits the growth of or destroys bacteria in the body]), and ensure Resident 5's peripherally inserted central venous catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart) was flushed every 12 hours as ordered in Resident 5's POFIT. 6. Ensure Resident 6's IV MAR for 7/2025 indicated to flush Resident 6's IV every 12 hours as ordered by Resident 6's physician in the POFIT dated 7/1/2025. 7. Ensure Resident 7's IV MAR dated 7/2025 indicated the frequency, start and stop dates for use of Zosyn (type of abx). As a result of these failures, Residents 1, 2, 3 and 5, 6's IV or PICC were not flushed every 12 hours as ordered. Residents 3 and 4's POFIT were not signed by their physicians. Resident 7's order for Zosyn did not have a start and stop dates. These failures put Residents 1, 2, 3, 4, 5, 6, and 7 at risk for complications with IV use and medication errors.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility was readmitted Resident 1 on 6/30/2025 with diagnoses that included urinary tract infection (UTIinfection that happen when bacteria enter the urethra, and infect the urinary tract) acute kidney failure (when the kidneys suddenly stop working due to complication of another serious illness), and unspecified hydronephrosis (a condition where urine backs up into the kidneys, causing them to swell, generally caused by infection or obstruction). During a review of Resident 1's IV MAR dated 6/30/2025 to 7/2025, the IV MAR indicated Resident 1 received one maintenance flush per day from 6/30/2025 to 7/5/2025. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/5/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had an active UTI. The MDS indicated Resident 1 was taking an abx. b. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/7/2023 and was readmitted on [DATE] with diagnoses that included sepsis (the body's extreme response to infection and a life-threatening medical emergency) due to Escherichia coli (E. coli- a type of bacteria commonly found in the intestines [gut] and urinary tract), UTI, and bacteremia (bacterial infection in the bloodstream). During a review of Resident 2's Residents Affected - Some 056228 Page 4 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IV MAR dated 6/2025, the IV MAR indicated Resident 2 received Meropenem (type of abx) from 6/19/2025 to 6/25/2025. The IV MAR indicated Resident 2 received one maintenance (IV) flush between 3 pm and 11 pm between 6/19/2025 and 6/25/2025. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 2 had a UTI in the last 30 days and was on abx. The MDS indicated Resident 2 had an IV present on admission for abx use. c. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 7/7/2025 with diagnoses that included pneumonia (PNA- an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus) due Mycoplasma pneumoniae (type of bacteria), unspecified respiratory failure (serious condition that makes it breathe on one's own) and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 3's IV MAR dated 7/2025, the IV MAR indicated Resident 3 received IV medication from 7/8/2025 to 7/13/2025. d. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 6/26/2025 with diagnoses that included chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should) stage three, and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 4 had active PNA, was on abx therapy, and had an IV present on admission. During a review of Resident 4's POFIT dated 7/7/2025, the POFIT indicated Resident 3 was ordered to receive ceftriaxone (type of abx) for treatment of UTI. During a review of Resident 4's IV MAR dated 7/2025, the IV MAR indicated Resident 4 received IV medication from 7/7/2025 to 7/11/2025. e. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 5/9/2025 with diagnoses that included acute (sudden onset) osteomyelitis (serious infection of the bone that be either be acute or chronic) of the left ankle and foot, type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and gangrene (dangerous and potentially fatal condition that happens when blood flow to a large area of tissue is cut off, breaks down then dies). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition. The MDS indicated Resident 5 had acute osteomyelitis of the left ankle and foot, was taking abx and had IV access. During a review of Resident 5's IV MAR dated 6/2025, the IV MAR indicated Resident 5 received IV cefepime (type of abx) from 6/5/2025 to 6/19/2025. f. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 7/1/2025 with diagnoses that included candidal sepsis (a severe bloodstream infection caused by Candida [type of fungus], which can lead to organ damage and even death), asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 6's IV MAR dated 7/2025, the IV MAR indicated Resident 6 was on IV medication from 7/1/2025 to 7/12/2025. During a review of Resident 6's MDS dated [DATE], the MDS indicated that Resident 6 had intact cognition. The MDS indicated Resident 6 was on IV medication and had IV access. g. During a review of Resident 7's AR, the AR indicated the facility admitted [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sepsis, bacteremia, and unspecified respiratory failure. During a review of Resident 7's IV MAR dated 7/2025, the IV MAR indicated Resident 7 was on Zosyn (type of abx) from 7/12/2025 to 7/16/2025. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. The MDS indicated Resident 7 had PNA and was on abx. During a concurrent interview and record 056228 Page 5 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review on 7/17/2025 at 10:19 am, with the MDS Coordinator (MDSC), Residents 1, 2, 3, 4, 5, 6, and 7's IV MAR and POFIT were reviewed. The MDSC stated Resident 1's POFIT dated 6/30/2025 did not indicate peripheral IV flush orders. The MDSC stated the orders were supposed to be filled out by the registered nurse (RN). The MDSC stated according to Resident 1's IV MAR dated 6/2025 to 7/2025, Resident 1 was only receiving one maintenance flush per day. The MDSC stated Resident 1 was supposed to be receive one maintenance flush every 12 hours. The MDSC stated the physician did not sign Resident 1's POFIT dated 6/30/2025. The MDSC stated according to Resident 2's POFIT dated 6/19/2025, LNs were to maintenance flush Resident 2's IV every 12 hours with 10 mL NS. The MDSC stated the physician's signature was missing from the POFIT. The MDSC stated according to the IV MAR dated 6/2025, LNs only maintenance flushed Resident 2's IV with 10 mL NS once a day not every 12 hours as ordered by Resident 2's physician. The MDSC stated Resident 3's POFIT dated 7/7/2025 was missing the physician's signature and did not indicate peripheral IV flush orders. The MDSC stated flush orders should be indicated in the POFIT. The MDSC stated dose of ceftriaxone (type of abx) was written as 29 but the ordered dose was supposed to be for two (2) grams (gm- unit of measurement). The MDSC stated according to Resident 3's IV MAR dated 7/2025 indicated to maintenance flush Resident 3's IV every 12 hours. The MDSC stated LNs were only maintenance flushing Resident 3's IV once a day. The MDSC stated the physician's signature was missing from Resident 4's POFIT dated 7/7/2025. The MDSC stated Resident 5's POFIT dated 5/9/2025 did not indicate what dose and at what frequency Resident 5 was to receive IV vancomycin. The MDSC stated the indicating diagnosis was missing from Resident 5's POFIT. The MDSC stated the physician ordered Resident 5's PICC to be flushed every 12 hours with 10 mL NS. The MDSC stated according to Resident 5's MAR dated 6/2025, LNs were only maintenance flushing Resident 5's PICC once a day. The MDSC stated Resident 6's IV MAR dated 7/2025 was supposed to indicate what maintenance flushes Resident 6 was to receive but was not indicated. The MDSC stated Resident 7's IV MAR dated 7/2025 was supposed to indicate the frequency, start and stop dates for Resident 7's Zosyn order, but were not indicated. The MDSC stated the IV needed to be complete because it was the official medical record. During an interview on 7/17/2025 at 2:13 pm, with the Director of Nursing (DON), the DON stated (in general) the IV MAR was filled out by RNs and needed to indicate the name of the IV medication, dose, frequency, start and stop dates. The DON stated the IV MAR needed to indicate what type of maintenance flush a resident was to received. The DON stated (in general) the POFIT needed to include the facility's name, order date and time, resident name and room/bed number and if the resident has DM or hypertension (condition where the force of blood against artery walls is consistently too high and blood pressure [BP- the pressure circulating blood against the walls of blood vessels; abnormal BP was less than 120/80 millimeters of mercury [mmHg- unit of measurement] and above 140/90 mmHg considered high blood pressure] is consistently high), the physician's name and signature, the LNs signature who obtained the order, resident's allergies, height, weight, laboratory values, and if they receive dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to). The DON stated the IV MAR and POFIT needed to be filled out accurately and completely so all staff know what the IV medication was to avoid medication errors, otherwise it could affect the resident's safety and could lead to complications like hospitalization or even death. The DON stated the POFIT needed to be signed by the physician because they are the ones ordering IV medications and their signatures verifies that what LNs write on the POFIT is correct. The DON stated there should always be maintenance flushes ordered with IVs to ensure patency (openness of IV line). The DON stated the standard of practice was for LNs to flush IVs (peripheral and PICC) every 12 hours and before and after medication administration. The DON stated IVs were not being flushed, the 056228 Page 6 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IV lines could become occluded (clogged) and could lead to blood clots and the inability to give medications to the residents, which could delay care or treatment. The DON stated the IV could need to be removed and replaced with a new line that could cause a resident pain or discomfort. The DON stated if there was a delay in care, it could affect the efficacy of the IV medication or complications to the resident's illness. During a review of the facility's P&P titled, Medication Orders, revised 1/2025, the P&P indicated medications were administered only upon clear, complete, and signed order of the person lawfully authorized to prescribe (write medication orders). The P&P indicated medication orders specified the name of the medication, strength (where indicated), dose and dosage form, time or frequency of administration, route of medication, quantity or duration of therapy, and diagnosis or indicated for use. During a review of the facility's P&P titled, Peripheral Catheter Flushing, dated 3/2023, the P&P indicated that RNs and IV certified licensed vocational nurses (LVN) according to state law and facility policy were to perform IV flushing. The P&P indicated flushing was performed to ensure and maintain catheter (IV) patency and to prevent the mixing of incompatible medications/solutions. The P&P indicated a physician's order was required to flush a peripheral catheter. The P&P indicated to verify the physician order (before flushing). The P&P indicated the order must include the flushing agent, volume and frequency. The P&P indicated documentation in the medical record must include the date and time (of the flush), prescribed flushing agents, site assessment, resident response to procedure and/or medication, and resident teaching. During a review of the facility's P&P titled, Continuous Infusion of Medications and Solutions, dated 3/2023, the P&P indicated to verify the physician's order for administering IV medications. The P&P indicated documentation in the medical record included, but was not limited to the date and time, prescribed flushing agents, medication/solution, rate of infusion site assessment, complications and interventions, resident response to procedure and/or medication, and resident teaching 056228 Page 7 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide concise and clear documentation for six of seven sampled residents (Residents 2, 3, 4, 5, 6, and 7) according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to ensure: 1. Ensure Resident 2's intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) in the IV Therapy medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) (IV MAR) were legible (able to clearly read). 2. Ensure Resident 3's medication name and diagnosis in the IVMAR were legible. Ensure Resident 3's medication dose and diagnosis were on the Physician Order for Infusion (IV) Therapy (POFIT) were legible. 3. Ensure Resident 4's allergies, medication dose, and flush times were legible in the IV MAR. 4. Ensure Resident 5's allergies were documented on the IV MAR. 5. Ensure Resident 6's medication name and allergies in the IV MAR were legible. 6. Ensure Resident 7's allergies, IV flush times, and medication order were legible in the IV MAR. As a result of these failures, Residents 2, 3, 4, 5, 6, and 7's medical records were not legible. These failures had the potential for Residents 2, 3, 4, 5, 6, and 7 to receive inaccurate medications and/or doses, experience an allergic reaction to medications, and not receive IV flushes at the appropriate times. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/7/2023 and was readmitted on [DATE] with diagnoses that included sepsis due to Escherichia coli (E. coli- a type of bacteria commonly found in the intestines [gut] and urinary tract), urinary tract infection (UTI- infection that happen when bacteria enter the urethra, and infect the urinary tract), and bacteremia (bacterial infection in the bloodstream). During a review of Resident 2's IV MAR dated 6/2025, the IV MAR indicated Resident 2 received Meropenem (type of antibiotic) from 6/19/2025 to 6/25/2025. The IV MAR indicated Resident 2 received one maintenance (IV) flush (type of IV flush that it given at set times) between 3 pm and 11 pm between 6/19/2025 and 6/25/2025. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment too) dated 6/24/2025, the MDS indicated Resident 2 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 2 had a UTI in the last 30 days and was on antibiotic (abx- medication that inhibits the growth of or destroys bacteria in the body) therapy. The MDS indicated Resident 2 had an IV present on admission for abx use. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 7/7/2025 with diagnoses that included pneumonia (PNAan infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus) due Mycoplasma pneumoniae (type of bacteria), unspecified respiratory failure (serious condition that makes it breathe on one's own) and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 3's IV MAR dated 7/2025, the IV MAR indicated Resident 3 received IV medication from 7/8/2025 to 7/13/2025. c. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 6/26/2025 with diagnoses that included chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should) stage three, and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 4 had active PNA, was on abx therapy, and had an IV present on admission. During a review of Resident 4's POFIT dated 7/7/2025, the POFIT indicated Resident 3 was to receive ceftriaxone (type of abx) for 056228 Page 8 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatment of UTI. During a review of Resident 4's IV MAR dated 7/2025, the IV MAR indicated Resident 4 received IV medication from 7/7/2025 to 7/11/2025. d. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 5/9/2025 with diagnoses that included acute (sudden onset) osteomyelitis (serious infection of the bone that be either be acute or chronic) of the left ankle and foot, type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and gangrene (dangerous and potentially fatal condition that happens when blood flow to a large area of tissue is cut off, breaks down then dies). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition. The MDS indicated Resident 5 had acute osteomyelitis of the left ankle and foot, was taking abx and had IV access. During a review of Resident 5's IV MAR dated 6/2025, the IV MAR indicated Resident 5 received IV cefepime (type of abx) from 6/5/2025 to 6/19/2025. e. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 7/1/2025 with diagnoses that included candidal sepsis (a severe bloodstream infection caused by Candida [type of fungus], which can lead to organ damage and even death), asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 6's IV MAR dated 7/2025, the IV MAR indicated Resident 6 was on IV medication from 7/1/2025 to 7/12/2025. During a review of Resident 6's MDS dated [DATE], the MDS indicated that Resident 6 had intact cognition. The MDS indicated Resident 6 was on IV medication and had IV access. f. During a review of Resident 7's AR, the AR indicated the facility admitted [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sepsis, bacteremia (bacterial infection in the bloodstream), and unspecified respiratory failure. During a review of Resident 7's IV MAR dated 7/2025, the IV MAR indicated Resident 7 was on Zosyn (type of abx) from 7/12/2025 to 7/16/2025. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. The MDS indicated Resident 7 had PNA and was on abx. During a concurrent interview and record review on 7/17/2025 at 10:19 am, with the MDS Coordinator (MDSC), Resident 2, 3, 4, 5, 6, and 7's IV MAR and POFIT were reviewed. The MDSC stated, when filling out the time date on the IV MAR, the treatment time was to be documented on top, and the licensed nurse's initials to be documented below the time. The MDSC stated on Resident 2's IV MAR dated 6/2025, I cannot read what times (Resident 2's) IV was flushed. The MDSC stated on Resident 3's IV MAR dated 7/2025, the IV medication was not legible. The MDSC stated Resident 3 was ordered ceftriaxone. The MDSC stated the MDSC could not read Resident 3's diagnosis for IV. The MDSC stated Resident 3 the diagnosis was supposed to be Mycoplasma pneumoniae. The MDSC stated on Resident 4's IV MAR dated 7/2025, the MDSC could not read was times Resident 4's IV was flushed. The MDSC stated the IV MAR indicated to flush between three and one (referring to times), but the IV MAR should have indicated to flush Resident 4's IV between 3 pm and 11 pm. The MDSC stated, I don't know if the order is being followed because none of the flush times are not legible. The MDSC stated Resident 4's allergies were, Hard to read. The MDSC stated Resident 4 had allergies to non-steroidal anti-inflammatory drugs (NSAIDS- type of medication used to treat mild to moderate pain). The MDSC stated the dose of ceftriaxone was not legible. The MDSC stated, It (the dose) looks a ‘T' and not a number. The MDSC stated it was possible Resident 4 could get the wrong treatment. The MDSC stated on Resident 4's POFIT dated 7/2025, the dose for ceftriaxone was supposed to be one (1) gram (gm- unit of measurement), but looked like seven (7) gm. The MDSC stated on Resident 5's IV MAR dated 6/2025, the IV MAR did not indicate if Resident 5 had any allergies. The MDSC stated if Resident 5 had no known drug allergies 056228 Page 9 of 10 056228 07/17/2025 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (NKDA) it should be indicated in the IV MAR. The MDSC stated on Resident 6's IV MAR dated 7/2025, the IV medication was not legible. The MDSC stated Resident 6 had taken caspofungin (type of medication use to treat fungal infections). The MDSC stated Resident 6 had three allergies documented on the IV MAR that were not legible, but stated Resident 6 had 10 allergies documented in the electronic health record (EHR). The MDSC stated allergies needed to documented in the IV MAR to ensure Resident 6 did not receive any medication Resident 6 was allergic to, develop an allergic reaction and get sick. The MDSC stated for Resident 7's IV MAR dated 7/2025, Resident 7's allergies were not legible. The MDSC stated Resident 7 had allergies to phenytoin (type of medication used to treat seizures [sudden, controlled electrical disturbance in the brain that can cause temporary changes in behavior, movement, consciousness, or sensation]) and latex (type of rubber product). The MDSC stated the flush times on Resident 7's IV MAR from 7/12/2025 to 7/17/2025 were not legible. During an interview on 7/17/2025 at 2:13 pm, with the Director of Nursing (DON), the [NAME] stated all documentation (on the IV MAR and POFIT) needed to be filled out completely and legibly so all staff knew what the IV medication order was to avoid medication errors. The DON stated illegible documentation could affect a resident's safety and could lead to complications like hospitalization or even death. During a review of the facility's P&P titled, DocumentationNursing, implemented 2/9/2024, the P&P indicated the purpose was to provide documentation of resident status and care given by nursing staff. The P&P indicated nursing documentation would concise, clear, pertinent, and accurate. The P&P indicated MARs were completed with each medication completed. 056228 Page 10 of 10