Health inspection·March 17, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. A review of Resident 87's admission Record indicated the facility admitted Resident 87 on 1/8/2023, with diagnoses that included muscle wasting and atrophy (muscle shrinking), Alzheimer's disease, (progressive disorder that causes brain cells to waste away and die) and history of falling. A review of Resident 87's MDS dated [DATE], indicated Resident 87 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 87 required limited assistance with one person physical assist for transfer, walking, locomotion on and off unit, dressing, and toilet use and required extensive assistance with personal hygiene and bathing. A review of Resident 87's Care Plan, undated, indicated Resident 87 was at risk for falls. The nursing interventions included for the staff to place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. During an observation on 3/14/2023 at 10:12 am, with RN 2, Resident 87 was sitting at the edge of the bed with the call light hanging on the right side rails next to the head board. Resident 87 stated, she could not use her call light and was unable to reach it. During an interview on 3/14/2023 at 10:12 am, RN 2 stated, Resident 87 needed to have her call light within reach. RN 2 stated, Resident 87 needed to visibly see her call light so that she could use the call light to call for help. A review of the facility's policy and procedure titled Call light: Accessibility and Timely Response, dated 9/2/2022, indicated, the staff will ensure the call light is within reach of resident and secured, as needed. The P&P indicated the call light system will be accessible to residents while in their bed or other sleeping accommodations within the residents' room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 2 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide personal privacy for one of 20 sampled residents (Resident 77). Resident 77 was visible from the hallway with the lower part of the resident's body uncovered, exposing her adult brief and legs while in bed. Residents Affected - Few This deficient practice had the potential to violate Resident 77's right to privacy and negatively affect Resident 77's psychosocial well-being. Findings: A review of Resident 77's admission Record indicated the facility admitted the resident on 6/11/2022, with diagnoses that included epilepsy (a brain disorder that causes recurring, unprovoked seizures), profound intellectual disabilities (individuals who cannot live independently, and require close supervision and help with self-care activities for having very limited ability to communicate and physical limitations), quadriplegia (paralysis that affects all a person's limbs and body from the neck down), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), and unspecified anxiety disorder (a mental health condition which interferes with the ability to function). A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/6/2022, indicated the resident did not have the ability to make self understood and understand others, and was severely impaired in her cognitive skills (core skills the brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated the resident was totally dependent on the staff for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident was always incontinent of bowel and bladder. During an observation on 3/14/23 at 9:09 am, Resident 77 was observed awake, lying in a low bed, with bilateral 1/4 side rails up and a floor mat on the right side of the bed. Resident 77 was moving her lower extremities sideways left and right with the lower part of her body uncovered, and the resident's adult brief and legs exposed. The resident's privacy curtain was partially closed, and the resident's lower part of the body including her adult brief was visible from the hallway outside her room. During an interview with the Director of Staff Development (DSD) on 3/14/2023 at 9:09 am, the DSD confirmed that Resident 77's lower part of the body including her adult brief was visible from the hallway. The DSD proceeded to cover the resident's lower part of the body with the resident's blanket. The DSD stated that Resident 77 moved a lot and was a fall risk. The DSD stated the staff needed to monitor the resident closely that was why the staff could not completely close the resident's privacy curtain. The DSD stated that the staff could close the privacy curtain a little bit more to cover Resident 77 and prevent the resident's body from being exposed from the hallway. A review of the facility's policy and procedures titled, Promoting/Maintaining Resident Dignity, revised on 9/2/2022, indicated it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life. The policy indicated all staff will maintain resident privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 3 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 staff failed to follow their policy and procedures to accurately document the personal belongings/possessions of two of 20 sampled residents (Residents 9 and 62). a. For Resident 9, the facility staff did not update the resident's inventory sheet to include (two) electric-powered wheelchairs (EPWs) that were brought in and stored at the facility during the resident's admission to the facility. b. For Resident 62, the facility failed to record Resident 62's personal inventory upon admission to the facility on 3/11/2021. These deficient practices had the potential to cause a negative impact on Resident 9 and Resident 62's psychosocial well-being. Findings: a. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including difficulty in walking, severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure. A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 required limited, one-person assistance with transfers, walking, and locomotion on and off unit. The MDS indicated Resident 9 normally used walker and wheelchair for mobility devices. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. During an interview on 3/14/2023 at 9:56 am, Resident 9 stated he had brought (two) EPWs to the facility, but he did not know where they were stored. Resident 9 stated he was concerned the EPWs were not being recharged or maintained. During an interview on 3/15/2023 at 2:59 pm, the Director of Social Services (DSS) stated Resident 9 was admitted to the facility with two EPWs that were stored in the facility's storage room. The DSS stated she did not update Resident 9's inventory sheet to include the EPWs. During an interview on 3/15/2023 at 4:03 pm, the Maintenance Supervisor (MS) stated Resident 9 was admitted to the facility with two EPWs. The MS stated Resident 9 asked if the batteries of the EPWs could be recharged every two weeks. The MS stated there was no company that regularly serviced the units. During a concurrent observation, two EPWs, one of which would not turn on, were observed in the outside storage room. During an interview on 3/16/2023 at 10:47 am, the Infection Prevention Nurse (IPN) stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 4 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitting nurse or the staff who received the EPWs should have documented the EPWs in the inventory of belongings to ensure an accurate inventory necessary to protect the resident's belongings. During a concurrent review of Resident 9's inventory sheet titled, Resident's Clothing and Possessions, (undated), it indicated, No belongings upon admission. A review of the facility's policy and procedures titled, Resident Personal Belongings, dated 9/2/2022, indicated the following: 1. The facility must protect the resident's right to possess personal belongings and assure they would be rightfully returned to the resident or to the resident's representative in the event of the resident's death or discharge from the facility. 2. All resident personal items would be inventoried at the time of admission by the social services designee or another designated staff member and documentation retained in the medical record. 3. Additional possessions brought in during the duration of the resident's stay must be added to the existing personal belongings inventory listing. b. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 62 did not leave the facility since admission on [DATE]. A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 12/15/2022, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition. The MDS indicated Resident 62 was totally dependent (full staff performance every time) for eating, dressing, and personal hygiene. The MDS also indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's Clothing and Possessions, dated 8/10/2021, indicated two pajamas and one pair of gray pants. During an observation on 3/15/2023 at 2:20 pm in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. During an observation on 3/16/2023 at 9:19 am in Resident 62's room, Resident 62 was awake, alert, and verbal. Resident 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. During an interview on 3/16/2023 at 10:14 am, Certified Nursing Assistant 2 (CNA 2) stated Resident 62 wore a gown because Resident 62 did not have any clothes to wear. CNA 2 stated Resident 62's family did not provide any clothes. CNA 2 stated Resident 62 wore borrowed clothes from the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 5 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 laundry when Resident 62 had visitors which were returned to the laundry. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/16/2023 at 5:46 pm in Resident 62's room, Resident 62 was lying in bed with the HOB elevated and wore a hospital gown. Residents Affected - Some During a telephone interview on 3/17/2023 at 10:27 am, Resident 62's Responsible Party (RRP 1) stated Resident 62 had many clothes upon admission to the facility. RRP 1 stated the facility staff used to tell RRP 1 that Resident 62 was overdressed. RRP 1 stated Resident 62 had at least four shirts, four dresses, four pairs of pants to match every shirt, and white fluffy house shoes. RRP 1 stated the facility never informed RRP 1 that Resident 62 did not have any clothes. During an interview on 3/17/2023 at 11:31 am, the Hospice Certified Nursing Assistant (CHHA 1) stated Resident 62 wore a hospital gown since Resident 62 did not have any clothes. CHHA 1 stated Resident 62 used to have long sleeve blouses. CHHA 1 opened Resident 62's closet, two drawers located below the closet, and three drawers of the bedside drawers. Resident 62 did not have any clothing in these locations. During a concurrent interview and record review on 3/17/2023 at 3:19 pm, the Director of Nursing (DON) reviewed Resident 62's Clothing and Possessions inventory, dated 8/10/2021. The DON stated these were items added to Resident 62's inventory and should have another inventory upon admission to the facility. In a concurrent interview, the Director of Medical Records (DMR) stated DMR reviewed Resident 62's entire clinical record and did not locate Resident 62's inventory from admission. During a follow-up telephone interview on 3/17/2023 at 3:34 pm, RRP 1 stated Resident 62 had too many items and good clothes upon admission to the facility. RRP 1 did not take an inventory of Resident 62's clothes upon admission since RRP 1 could not enter the facility due to the Coronavirus-19 (COVID-19, infectious viral disease that can cause respiratory illness) restrictions. A review of the facility's policy and procedures titled, Resident Personal Belongings, revised on 9/2/2022, indicated All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 6 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and care planning tool) for one of 20 sampled residents (Residents 57) accurately reflected the resident's bladder (organ that stores urine) function. Residents Affected - Few This deficient practice had the potential to result in inconsistencies and delay of individualized care and services for Residents 57. Findings: A review of Resident 57's admission Record indicated the facility admitted Resident 57 on 5/25/2018, with diagnoses of difficulty in walking, repeated falls, and gastro-esophageal reflux disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus). A review of Resident 57's MDS dated [DATE], indicated Resident 57 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 57 required extensive assistance with one person physical assist for transfer, dressing, and toilet use. The MDS indicated Resident 57 had an indwelling catheter (a tube inserted into the bladder used to drain urine from the bladder to the tube and the drainage bag) and was always continent (able to control) of bladder. During a concurrent observation and interview with Resident 57 on 3/14/2023 at 11:10 am, Resident 57 was sitting in her wheelchair in the activity room without an indwelling urinary catheter. Resident 57 stated she never had an indwelling urinary catheter in place while in the facility. During an interview on 3/14/2023 at 11:12 am, RN 2 stated, Resident 57 did not have an indwelling urinary catheter. RN 2 stated, Resident 57 was continent of bladder. During an interview on 3/15/2023 at 9:33 am, the MDS Nurse (MDSN) stated, she saw Resident 57 physically and stated the resident did not have an indwelling urinary catheter currently and in 2/2023. The MDSN stated, she miscoded the resident's MDS dated [DATE] under the bladder section. The MDSN stated the MDS was the resident's assessment and needed to be accurate. A review of the facility's policy and procedures (P&P) titled, MDS 3.0 Completion, dated 9/2/2022, indicated that according to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 7 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - 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 observation, interview, and record review, the facility failed to develop care plans for four of 20 sampled residents (Resident 13, 62, 1, and 9). a. For Resident 13, the facility did not develop a care plan for a Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNAs) to help residents maintain their function and joint mobility] for ambulation (walking) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendation on 6/17/2022. This deficient practice prevented Resident 13 from walking for nine months since discharge from PT. b. For Resident 62, who had impaired range of motion [ROM, full movement potential of a joint (where two bones meet)] in both arms and both legs, the facility did not develop a care plan to address Resident 62's decreased ROM and mobility. This deficient practice had the potential for Resident 62 to develop ROM limitations, including the development of contractures (chronic loss of joint motion associated with deformity and joint stiffness). c. For Resident 1, who had impaired ROM in both arms and both legs, the facility did not develop a care plan to address Resident 1's decreased ROM and mobility. This deficient practice had the potential for Resident 1 to develop ROM limitations, including the development of contractures. d. For Resident 9, the facility staff did not develop a care plan for the resident's inability to sleep for which Melatonin (supplement to induce sleep) and Trazodone (antidepressant medication that can induce sleep) were ordered. This deficient practice had the potential to cause excessive sleep for Resident 9. Findings: a. A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021, with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's PT Treatment Encounter Note(s), dated 6/17/2022, indicated Physical Therapist 1 (PT 1) discussed with Resident 13 about Resident 13's discharge from PT. The PT Treatment Encounter Note indicated Resident 13 agreed to transition to the Restorative Nursing Program (RNP) for ambulation. A review of Resident 13's PT Discharge summary, dated [DATE], indicated Resident 13 was safely ambulated on level surfaces for 60 feet using a two-wheeled walker with minimum assistance from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 8 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff on 6/17/2022. The Discharge Summary indicated Resident 13 had a good prognosis to maintain Resident 13's current level of functioning with consistent staff follow-through. A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), understood others, and expressed ideas and wants. The MDS indicated Resident 13 required limited one-person assistance and/or guided maneuvering of limbs with walking. The MDS indicated Resident 13's balance during transitions and walking was not steady and only able to stabilize with staff assistance. During an interview on 3/15/2023 at 2:44 pm, the Director of Rehabilitation (DOR) stated the residents on RNP did not have any physician's orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a resident's care plan. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings with the RNAs once per month. During an interview on 3/15/2023 at 2:52 pm, the DOR and MDSA stated a resident's RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a resident's functional status. During an interview and concurrent review of Resident 13's clinical records on 3/16/2023 at 6:01 pm, the MDSA stated RNA was recommended for ambulation when Resident 13 was discharged from PT on 6/17/2022. The MDSA stated MDSA reviewed Resident 13's entire clinical record and did not locate a care plan for RNA after discharge from PT on 6/17/2022. The MDSA stated the task for RNA was not created since Resident 13 did not have a care plan for RNA. The MDSA stated there was no documented evidence Resident 13 was seen for ambulation with RNA after discharge from PT on 6/17/2022. During an interview on 3/17/2023 at 11:49 am, the Director of Nursing (DON) stated care plans were important because it guided the resident's care. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Cross reference F688 b. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 required limited assistance (resident highly involved in activity) for eating and required extensive assistance (resident involved in activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 9 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some while staff provide weight-bearing support) for dressing and personal hygiene. The MDS indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs), dated 3/11/2021, indicated Resident 62 had limited ROM in the left shoulder, left elbow, left wrist, left hand/fingers, both knees, and both ankles. The JMA indicated Resident 62's ROM in the right shoulder was above shoulder height, the right elbow had full ROM (straighten and bend without limitations), the right wrist had full ROM, the right hand/fingers had full ROM, and both hips bent to hip height. A review of Resident 62's Change of Condition JMA, dated 1/12/2022, indicated Resident 62 had limited ROM in the right ring finger and right little finger, left hand/finger, both knees, and both ankles. The JMA indicated Resident 62's ROM in both shoulders was above shoulder height, the right elbow had full ROM, the left elbow had nearly full ROM, ROM in both wrists moved from a slightly bent position to a fully bent position, and both hips bent to hip height. A review of Resident 62's MDS, dated [DATE], 6/30/2022, 9/26/2022, and 12/15/2022, indicated Resident 62 had functional ROM limitations in both arms and both legs. During an observation on 3/15/2023 at 2:20 pm in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Resident 62 reached forward with slight movement at the right shoulder joint and slight extension of the right elbow. Resident 62's right wrist was completely bent downward, and Resident 62's thumb and fingers on the right hand were bent around a rolled-up hand towel. Resident 62 did not have any active movement in the left arm. Resident 62's left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. During an observation on 3/15/2023 at 2:27 pm in Resident 62's room, Certified Nursing Assistant 8 (CNA 8) had Resident 62's permission to remove the blanket over both legs. Resident 62 lifted the right leg very slightly at the hip joint but did not have any other active movement in the right leg and throughout the left leg. Both of Resident 62's ankles were bent away from the body. During an interview on 3/17/2023 at 11:49 am, the Director of Nursing (DON) stated care plans were important because it guided the resident's care. During an interview on 3/17/2023 at 12:48 pm, the DON and the DOR reviewed Resident 62's MDS assessments. Both the DON and DOR stated Resident 62 did not have an active care plan to address Resident 62's ROM limitations. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated the facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Cross reference F688 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 10 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm c. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 8/1/2008, and readmitted the resident on 2/15/2023. Resident 1's diagnoses included but was not limited to kidney failure, dysphagia (difficulty swallowing), attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), history of transient ischemic attack (brief stop of blood supply to the brain) and cerebral infarction (brain damage due to a loss of oxygen to the area) without residual deficits. Residents Affected - Some A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 2/21/2023, indicated Resident 1 had unclear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 was totally dependent (full staff performance every time) for bed mobility, transfers between surfaces, dressing, eating, hygiene, toileting, and bathing. The MDS indicated Resident 1 had functional ROM limitations in both arms and both legs. A review of Resident 1's re-admission Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs), dated 2/16/2023, indicated Resident 1 raised both arms at the shoulder joint to shoulder height and had full ROM in both elbows (straighten and bend without limitations), full ROM in both wrists, nearly full ROM in both hands, full ROM in both hips, full ROM in both knees, and full ROM in both ankles. During an observation on 3/15/2023 at 8:23 am in Resident 1's room, Resident 1 was lying in bed with the HOB elevated. Resident 1 was awake and had both hands interlocked in the middle of Resident 1's body. There was blanket over both of Resident 1's legs. During an observation on 3/15/2023 at 8:57 am, Treatment Nurse 2 (TXN 2) came out of Resident 1's room after changing the G-tube dressing. TXN 2 returned to Resident 1's room to remove the blanket over Resident 1's legs. Resident 1 had a pillow placed in-between both legs. Resident 1's left leg was crossed above the right leg. During an interview on 3/16/2023 at 10:42 am, Certified Nursing Assistant 3 (CNA 3) stated Resident 1 moved both arms but did not move both legs. CNA 3 stated Resident 1 required a pillow between Resident 1's legs since Resident 1 tended to cross the legs. During an interview on 3/17/2023 at 11:49 am, the Director of Nursing (DON) stated care plans were important because it guided the resident's care. The DON stated Resident 1 did not have an active care plan to address Resident 1's ROM limitations. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated the facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Cross reference F688 d. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder), hypertensive heart disease (heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 11 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some problems due to high blood pressure over a long period of time) with heart failure, major depressive disorder (persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (developed by individuals who experienced a shocking, scary, or dangerous event with symptoms like trouble sleeping and nightmares). A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 had sleeping problems nearly every day. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. A review of Resident 9's active physician orders from 3/1/2023 through 3/17/2023 indicated the following orders: 1. Give 1 tablet of Melatonin tablet 5 milligrams orally at bedtime for sleep. 2. Give 1 tablet of Trazodone HCl 100 milligrams orally at bedtime for depression manifested by inability to sleep. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 9:39 am, Licensed Vocational Nurse 3 (LVN 3) stated the licensed nurse must clarify the order with the physician if it was necessary to administer two different medications to treat the sleeping problem. LVN 3 stated all licensed staff must be aware of the care plan and ensure Resident 9's safety. During an interview on 3/16/2023 at 9:50 am, Registered Nurse 2 (RN 2) stated Melatonin and Trazodone were both ordered as a sleep aid for Resident 9. RN 2 stated by administering both medications at the same time, the licensed nurse would be unable to determine the effectiveness of each medication or identify which medication was causing an adverse effect. RN 2 stated administering both medications could cause a drug interaction, which could potentially lead to falls or oversedation. During a follow-up interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 11:03 am, RN 2 stated there were no notes or a care plan addressing Resident 9's sleeping problem to address the administration of both Resident 9's Melatonin and Trazodone at the same time. RN 2 stated the licensed nurse must initiate a care plan to address Resident 9's inability to sleep, verify the orders with the physician, and clarify for any possible drug interactions and inform Resident 9. A review of the facility's policy and procedures, titled Comprehensive Care Plans, dated 9/2/2022, indicated the following: 1. The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. 2. The resident comprehensive care plan must describe the resident-specific interventions that reflect the resident's needs and preferences. 3. The comprehensive care plan must be reviewed and revised by the interdisciplinary team after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 12 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 each comprehensive and quarterly MDS assessment. Level of Harm - Minimal harm or potential for actual harm 4. The physician, other practitioner, or professional must inform the resident and/or resident representative of the risks and benefits of the proposed care, of treatment, and treatment alternatives/options. Residents Affected - Some 5. Qualified staff responsible for carrying out interventions specified in the care plan must be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 13 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 appropriate services to maintain activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) for one of five sampled residents (Resident 62) with mobility and range of motion concerns. Residents Affected - Few This deficient practice resulted in Resident 62's decreased mobility, including transfers to a wheelchair and assistance to go out of Resident 62's room. Findings: A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 62 did not leave the facility since admission on [DATE]. A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 responded it was somewhat important to do things with groups of people, do favorite activities, and go outside to get fresh air when the weather was good. The MDS indicated Resident 62 was totally dependent (full staff performance every time) for transfers between surfaces and locomotion on unit (how resident moves between locations in the room and adjacent corridor). The MDS indicated Resident 62 participated in locomotion off unit (how resident moves to and from distant areas in the facility) only once or twice during the seven-day assessment period. A review of Resident 62's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Progress and Discharge summary, dated [DATE], indicated Resident 62 met short-term goals which included sitting upright in a chair/wheelchair with proper positioning for 60 minutes. The PT Discharge Plan indicated to use a mechanical lift when transferring Resident 62 into the assigned wheelchair. A review of Resident 62's care plan for ADL self-care performance, dated 7/13/2021 and revised on 7/8/2022, indicated an intervention to provide Resident 62 with total assistance with transfers requiring two person assist using a mechanical lift. Resident 62's care plan for ADLs did not include interventions to address locomotion off unit and locomotion on unit. A review of Resident 62's admission Order, dated 1/12/2022, indicated Resident 62 was admitted to hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 14 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few each day as fully as possible) with a diagnosis of Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). Resident 62's hospice admission Order indicated an activity order for transfers from bed to chair. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 responded it was somewhat important to do favorite activities and to go outside to get fresh air when the weather was good. The MDS indicated Resident 62 was totally dependent for transfers between surfaces, locomotion on unit, and locomotion off unit. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 was totally dependent for transfers between surfaces, locomotion on unit, and locomotion off unit. A review of Resident 62's Documentation Survey Report (electronic record of care) for 12/2022 indicated locomotion off unit was NA (not applicable) for Resident 62 for the entire month (31 days). The Documentation Survey Report for 12/2022 indicated Resident 62 was totally dependent for locomotion on unit on 12/25/2022 and 12/28/2022 but was not applicable for all other dates in the month (29 days). A review of Resident 62's Documentation Survey Report for 1/2023 indicated locomotion off unit and locomotion on unit was not applicable for the entire month (31 days). A review of Resident 62's Documentation Survey Report for 2/2023 indicated Resident 62 was totally dependent for locomotion on unit and locomotion off unit on 2/18/2023 and 2/19/2023. Resident 62's Documentation Survey Report indicated locomotion on unit and locomotion off unit was not applicable for all other dates in the month (26 days). A review of Resident 62's Activity Attendance Record for 2/2023 indicated Resident 62 participated in room visits for music, sensory stimulation, and watching television or a movie. Resident 62's Activity Attendance Record did not indicate Resident 62 participated in activities in the activity room for the entire month. A review of Resident 62's Documentation Survey Report for 3/2023 indicated Resident 62 required limited assistance (resident highly involved in activity, staff provided guided assistance) for locomotion on unit and locomotion off unit on 3/13/2023. Resident 62's Documentation Survey Report indicated locomotion on unit and off unit was not applicable from 3/1/2023 to 3/12/2023 and 3/14/2023 to 3/16/2023. A review of Resident 62's Activity Attendance Record for 3/2023 indicated Resident 62 participated in room visits for music, sensory stimulation, video calls, and watching television or a movie. Resident 62's Activity Attendance Record did not indicate Resident 62 participated in activities in the activity room for the entire month. During an observation on 3/14/2023 at 10:37 am in Resident 62's room, Resident 62 was sleeping while lying in bed. During an observation and interview on 3/15/2023 at 2:20 pm in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Resident 62 reached forward with slight movement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 15 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at the right shoulder joint and slight extension of the right elbow. Resident 62's right wrist was completely bent downward, and Resident 62's thumb and fingers on the right hand were bent around a rolled-up hand towel. Resident 62 did not have any active movement in the left arm. Resident 62's left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. Resident 62 stated the facility staff did not assist Resident 62 out of bed. There was no wheelchair observed in Resident 62's room. During an observation and interview on 3/16/2023 at 9:19 am in Resident 62's room, Resident 62 was awake, alert, and verbal. Resident 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. Resident 62 stated Resident 62 would love to go to the activity room but did not have a wheelchair. There was no wheelchair observed in Resident 62's room. During an interview on 3/16/2023 at 10:14 am, Certified Nursing Assistant 2 (CNA 2) stated Resident 62 did not take showers in the shower room and only received bed baths because Resident 62 was on hospice care. CNA 2 stated Resident 62 was usually repositioned in bed and did not get out of the bed. CNA 2 stated Resident 62 did not have visitors often but was transferred to the gerichair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) for visits. During an observation on 3/16/2023 at 11:29 am, Resident 62's bathroom did not have any wheelchair for Resident 62. During an interview and record review on 3/17/2023 at 3:40 pm, the Director of Nursing (DON) reviewed Resident 62's PT Discharge Summary and stated PT recommended a mechanical lift to transfer Resident 62 into a wheelchair. The DON reviewed Resident 62's Documentation Survey Report for locomotion off unit and locomotion on unit and confirmed the report indicated not applicable for Resident 62. The DON stated Resident 62 had no restrictions to get out of bed. During a telephone interview on 3/17/2023 at 4:16 pm, the Hospice Registered Nurse (HRN 1) stated HRN 1 had never seen Resident 62 out of bed. HRN 1 stated Resident 62 could transfer into a gerichair which would improve Resident 62's quality of life, make Resident 62 happy, and allow Resident 62 to have something to look forward to. A review of the facility's policy and procedures titled, Activities of Daily Living (ADLs), revised on 9/2/2022, indicated assisting with transfers was part of the care and services the facility may provide for ADLs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 16 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 83) with pressure ulcers (areas of damaged skin caused by staying in one position for too long) had the resident's low air loss mattress (LAL, a mattress designed to prevent and treat pressure ulcers) set at the correct setting based on the resident's weight. Resident 83 weighed 100 pounds and Resident 83's LAL mattress was set at 160 pounds. Residents Affected - Few This deficient practice had the potential to result in worsening and/or delay in healing of Resident 83's pressure ulcers. Findings: A review of Resident 83's admission Record indicated the facility initially admitted Resident 83 on 1/19/2023, and re-admitted the resident on 1/29/2023, with diagnosis that included respiratory failure (the lungs failed to exchange gas effectively), cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), quadriplegia (paralysis of all four limbs) and multiple pressure ulcers (painful wound caused as a result of pressure or friction). A review of Resident 83's Order Summary Report dated 1/19/23, indicated a physician's order for LAL mattress for wound management and for the staff to monitor LAL placement and function every shift. A review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/2/2023, indicated the resident had moderate impairment in cognitive (ability to think and process information) skills, had multiple pressure ulcers (areas of damaged skin caused by staying in one position for too long) and required total dependence (full staff performance every time) from staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 83's Skin Only Evaluation dated 3/13/2023, indicated the resident had stage 3 (full thickness skin loss) pressure ulcers/injuries on the sacrococcyx (pertaining to both the sacrum and coccyx [the tailbone]), right heel, right midback, and right ear. During an observation, on 3/14/2023 at 9:58 am, Resident 83's low air loss mattress was set at 160 pounds. During a concurrent observation and interview with the Infection Prevention Nurse (IPN), on 3/14/2023 at 10 am, the IPN stated that Resident 83 was at high risk for pressure ulcers to the back and that the resident was unable to move independently in bed. The IPN confirmed that the Resident 83's LAL was set at 160 pounds. The IPN stated, the treatment nurse (TXN 1) was responsible for checking the resident's LAL mattress setting. During an interview with TXN 1, on 3/14/2023 10 am, TXN 1 stated that she was not aware that Resident 83's LAL mattress was at the wrong setting. TXN 1 stated that the resident weighed 100 pounds and not 160 pounds. TXN 1 stated that it was important to set the LAL mattress based on manufacturer recommendation which was to set the LAL mattress according to the resident's weight to promote wound healing. TXN 1 stated that the LAL mattress should not be set too soft or too hard because the pressure ulcer could worsen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 17 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a follow-up interview and concurrent review of Resident 83's weight log, on 3/14/2023 at 10: 10 am, the TXN 1 stated that Resident 83 weighed 100 pounds on 3/13/2023. A review of the facility's policy and procedures dated 9/2/2022 titled, Use of Support Surfaces, indicated Support surface refers to a specialized mattress, mattress overlay, or chair cushion designed to manage pressure, shear, microclimate, or friction forces on tissue. The policy indicated support surfaces will be utilized in accordance with manufacturer recommendations. A review of the Operation Manual for Resident 83's LAL mattress, undated, indicated users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 18 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to three of five sampled residents (Residents 62, 1, and 13) with mobility (ability to move) and range of motion [ROM, full movement potential of a joint (where two bones meet)] concerns. a. For Resident 62, the facility failed to: 1. Perform an annual Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs) since 1/12/2022 (over one year) in accordance with the facility's policy. 2. Provide passive range of motion (PROM, movement of a joint through the ROM with no effort from the resident) or any splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both arms and both legs since 4/5/2022 (over 11 months) in accordance with the facility's policy for Restorative Nursing Programs [RNP, nursing program that use a restorative nursing aide (RNA) to help residents maintain their function and joint mobility]. These deficient practices had the potential for Resident 62 to experience a decline in range of motion, including the development and worsening of contractures (deformity and joint stiffness) in both arms and both legs, making it difficult to dress Resident 62 in normal clothes. These deficient practices also had the potential to cause Resident 62 increased pain with movement and contribute to the development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). b. For Resident 13, the facility did not provide RNP services with the RNA for ambulation (walking) after discharge from Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 6/17/2022 (nine months). This deficient practice had the potential to cause a decline in Resident 13's ability to walk. c. For Resident 1, the facility failed to provide ROM exercises to both arms and both legs in accordance with the facility's policy for RNP since 3/9/2023. This deficient practice had the potential for Resident 1 to develop ROM limitations, including the development of contractures. Cross reference F656. Findings: a. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 19 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 interfere with one's daily activities), and hypertension (abnormally high blood pressure). Level of Harm - Minimal harm or potential for actual harm A review of Resident 62's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 62 did not leave the facility since admission on [DATE]. Residents Affected - Some A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Resident 62 had clear speech, sometimes expressed ideas, and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 required limited assistance (resident highly involved in activity) for eating and required extensive assistance (resident involved in activity while staff provide weight-bearing support) for dressing and personal hygiene. The MDS also indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's JMA, dated 3/11/2011, indicated Resident 62 had limited ROM in the left shoulder, left elbow, left wrist, left hand/fingers, both knees, and both ankles. The JMA indicated Resident 62's ROM in the right shoulder was above shoulder height, the right elbow had full ROM (straightened and bent without limitations), the right wrist had full ROM, the right hand/fingers had full ROM, and both hips bent to hip height. A review of Resident 62's Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] Plan of Care, dated 3/11/2021, indicated Resident 62 had more ROM limitations in the left arm than the right arm. The OT Plan of Care indicated the left arm had spasticity (increased muscle stiffness) which positioned the elbow in extension (straight), fingers in flexion (bent), neutral shoulder (arm positioned parallel to the body), and neutral wrist (straight with the palm in line with the wrist). The OT Plan of Care included OT treatment five times a week for four weeks. A review of Resident 62's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Plan of Care, dated 3/11/2021, indicated Resident 62 had ROM limitations both legs. The PT Plan of Care indicated both of Resident 62's knees bent to five degrees of motion (normal is 140 degrees of motion) and both hips had 20 degrees of limited flexion (hips bent to hip height). The PT Plan of Care indicated Resident 62 had 10 out of 10 (severe) pain in both thighs. The PT Plan of Care included PT treatment five times a week for four weeks. A review of Resident 62's OT Progress and Discharge summary, dated [DATE], indicated Resident 62 met a short-term goal to tolerate the application of a left-hand splint for three hours. The OT Progress and Discharge Summary also indicated Resident 62 met a long-term orthotic (splint) goal which indicated the RNP applied and removed the left-hand splint and monitored Resident 62's skin condition for effective contracture prevention and joint protection. The OT Discharge Plan indicated Resident 62 was referred to the RNP for application of the left-hand splint and PROM program. A review of Resident 62's PT Progress and Discharge summary, dated [DATE], indicated Resident 62 met short-term goals which included sitting upright in a chair/wheelchair with proper positioning for 60 minutes, reporting decreased pain in both knees and hip joints to moderate pain, and improved PROM of both knees to 60 degrees of flexion. The PT Progress and Discharge Summary also indicated RNP training included education to the nurses for proper positioning and techniques to inhibit extensor tone (prevent excessive straightening) in both of Resident 62's legs. The PT Discharge Plan indicated Resident 62 was referred to RNP with an exercise program and to use a mechanical lift when transferring Resident 62 into the assigned wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 20 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 A review of Resident 62's Restorative Administration Record (record of RNA sessions) for 4/2021 indicated Resident 62 received the following RNA services: Level of Harm - Minimal harm or potential for actual harm - 4/5/2021 to 4/30/2021: RNP for PROM to both legs one time per day, every day, three times per week Residents Affected - Some - 4/5/2021 to 4/30/2021: RNP for PROM on the left arm one time per day, every day, three times per week - 4/5/2021 to 4/6/2021: RNP splinting program one time per day, every day, three times per week - 4/7/2021 to 4/30/2021: Refer to RNP for splinting program one time a day, every day, three times per week to apply the inflatable hand roll (hand splint placed in the palm with an inflatable air bladder to apply a low stretch to contracted fingers) for up to three hours to the left hand. A review of Resident 62's Restorative Administration Record for 5/2021 indicated Resident 62 received the following physician's orders and RNA services from 5/1/2021 to 5/31/2021: - 4/6/2021: RNP for PROM exercises to both legs, one time a day, every day, three times per week - 4/6/2021: RNP for PROM program for the left arm, one time a day, every day, three times per week - 4/8/2021: RNP for splinting program to apply an inflatable hand roll to the left hand for up to three hours, one time a day, every day, three times per week A review of Resident 62's Restorative Administration Record indicated Resident 62 continued to receive RNA services in accordance with the physician's orders from 6/2021 to 2/2022. A review of Resident 62's Change of Condition JMA, dated 1/12/2022, indicated Resident 62 had limited ROM in the right ring finger and right little finger, left hand/finger, both knees, and both ankles. The JMA indicated Resident 62's ROM in both shoulders was above shoulder height, the right elbow had full ROM, the left elbow had nearly full ROM, ROM in both wrists moved from a slightly bent position to a fully bent position, and both hips bent to hip height. A review of the OT Evaluation and Plan of Treatment (OT Evaluation), dated 1/12/2022, indicated Resident 62's primary physician referred Resident 62 to OT services to evaluate the ROM in both arms due to a specific decline in finger extension in the ring finger and little finger of the right hand. The OT Evaluation indicated Resident 62 had the following ROM: - Right shoulder: Within functional limits (WFL, sufficient joint movement without significant limitation) - Right elbow/forearm: WFL - Right wrist: Impaired - Right hand: Impaired - Right thumb: WFL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 21 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 - Right index finger: WFL Level of Harm - Minimal harm or potential for actual harm - Right middle finger: WFL - Right ring finger: Impaired Residents Affected - Some - Right little finger: Impaired - Left shoulder: WFL - Left elbow/forearm: WFL - Left wrist: WFL - Left hand: Impaired - Left thumb: Impaired - Left index finger: Impaired - Left middle finger: Impaired - Left ring finger: Impaired - Left little finger: Impaired. The OT Evaluation indicated Resident 62 already had an inflatable hand roll splint for the left-hand contractures to prevent further decline and indicated Resident 62 was developing contractures to the right hand ring finger and little finger. The OT recommendation for Resident 62 included placement of hand roll splints in both hands to maintain joint mobility. The OT clinical impression indicated Resident 62 presented with functional decline and indicated nursing referred Resident 62 to hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible). The OT Evaluation did not recommend further therapy services. A review of Resident 62's admission Order, dated 1/12/2022, indicated Resident 62 was admitted to hospice care with a diagnosis of Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). Resident 62's hospice admission Order indicated Resident 62 may continue all routine medications and treatments. A review of Resident 62's electronic record for RNP included the following RNP tasks: - 2/24/2022: PROM to both arms, daily, three times per week, as tolerated - 2/25/2022: splint/care assistance to left hand, daily, three times per week, as tolerated - 3/2/2022: PROM to both legs, daily, three times per week, as tolerated. Resident 62's RNP record, dated 2/25/2022, did not indicate the amount of time to apply the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 22 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some left-hand splint. Resident 62's RNP record did not include a right-hand splint in accordance with the OT Evaluation recommendation on 1/12/2022. A review of Resident 62's RNP Documentation Survey Report (electronic record of RNA sessions) for 3/2022 indicated Resident 62 received RNP services three times per week for PROM to both arms, left hand splint application, and PROM to both legs from 3/2/2022 to 3/30/2022. A review of Resident 62's RNP Documentation Survey Report for 4/2022 indicated Resident 62 received RNP services for PROM to both arms, left hand splint application, and PROM to both legs on 4/1/2022 and 4/4/2022. A review of Resident 62's electronic record for RNP indicated the RNP tasks for PROM to both arms, application of the left splint/care, and PROM to both legs were resolved (discontinued) on 4/5/2022. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 had clear speech, sometimes expressed ideas, and wants, sometimes understood verbal content, and had severely impaired cognition. The MDS indicated Resident 62 was totally dependent (full staff performance every time) for eating, dressing, and personal hygiene. The MDS also indicated Resident 62 had functional ROM limitations in both arms and both legs. During an observation and interview on 3/15/2023 at 2:20 PM in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Resident 62 reached forward with slight movement at the right shoulder joint and slight extension of the right elbow. Resident 62's right wrist was completely bent downward, and Resident 62's thumb and fingers on the right hand were bent around a rolled-up hand towel. Resident 62 did not have any active movement in the left arm. Resident 62's left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. Resident 62 stated Resident 62 did not remember if any facility staff member provided any exercises to both arms and both legs. During an observation on 3/15/2023 at 2:27 PM in Resident 62's room, Certified Nursing Assistant 8 (CNA 8) had Resident 62's permission to remove the blanket over both legs. Resident 62 lifted the right leg very slightly at the hip joint but did not have any other active movement in the right leg and throughout the left leg. Both of Resident 62's ankles were bent away from the body. During an interview on 3/15/2023 at 2:44 PM, the Director of Rehabilitation (DOR) stated the residents on RNP did not have any physician's orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a resident's care plan. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings once per month. During an interview on 3/15/2023 at 2:52 PM, the DOR and MDSA stated a resident's RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a resident's ROM and to maintain a resident's functional status. The DOR stated residents who did not move at all or had weakness were at risk for developing contractures. During an observation and interview on 3/16/2023 at 9:19 AM in Resident 62's room, Resident 62 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 23 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some awake, alert, and verbal. Resident 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. A rolled-up hand towel was resting on top of Resident 62's left hand instead of inside the left palm. Resident 62 stated the hand towel sometimes came out of the left hand. Resident 62 continued to have minimal active movement in the right shoulder and right elbow to reach forward. Resident 62 was unable to move the right wrist, which was positioned in a completely bent position, and the right fingers, which were positioned into a fist. Resident 62 continued to have no movement in the left arm and both ankles were bent away from the body. Restorative Nursing Aide 1 (RNA 1) walked into Resident 62's room. In a concurrent interview, RNA 1 stated Resident 62 did not receive RNA services for ROM but assisted Resident 62 with feeding. During a follow-up interview on 3/16/2023 at 9:35 AM, RNA 1 stated Resident 62 did not receive RNA for ROM since Resident 62 was on hospice. During an interview on 3/16/2023 at 10:50 AM, Restorative Nursing Aide 2 (RNA 2) stated RNA 2 did not work with Resident 62 since Resident 62 was on hospice. During an interview on 3/16/2023 at 11:47 AM, the Director of Nursing (DON) stated the facility's nurses provided nursing care for hospice residents and the hospice company provided additional services. The DON stated residents on hospice were treated the same as any other resident in the facility. During a follow-up interview on 3/16/2021 at 4:15 PM, the DON stated residents on hospice received the same care provided to all other residents, including medication management, pain management, activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), and RNA services for ROM. The DON stated some families did not want the resident on hospice to receive RNA services. The DON stated the facility coordinated care with the hospice company if the family did not want a resident to receive RNA services. During an interview and record review on 3/16/2023 at 3:09 PM, the DOR reviewed Resident 62's PT Progress and Discharge summary, dated [DATE], which included recommendations for RNP exercises. The DOR reviewed Resident 62's OT Progress and Discharge summary, dated [DATE], which included recommendations for a left-hand roll splint and RNP for PROM. The DOR stated Resident 62 received another OT evaluation on 1/12/2022 which included a recommendation for a right-hand roll splint. In a concurrent interview and observation, the Assistant Director of Rehabilitation (ADOR) provided a demonstration of an inflatable hand roll splint. The ADOR stated PROM should be performed prior to applying the splint. The ADOR brought out a blue colored splint which had an internal plastic air pocket that could be inflated. The ADOR connected a small manual pump to the plastic air pocket to inflate the splint. The ADOR stated the inflatable hand roll splint was secured to the hand with a Velcro strap. The ADOR stated the inflatable hand roll splint prevented further contractures to the hand and provided skin protection to the palm. During an interview and record review on 3/16/2023 at 5:09 PM, the DOR reviewed Resident 62's initial JMA, dated 3/11/2021. The DOR stated Resident 62 had the following ROM in both arms and both legs: - Right shoulder: WFL - Right elbow: WFL - Right wrist: WFL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 24 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 - Right hand: WFL Level of Harm - Minimal harm or potential for actual harm - Right hip: WFL - Right knee: 20-30 degrees (10 degrees of motion, normal 0-140 degrees) Residents Affected - Some - Right ankle: 0-10 degrees into plantarflexion (ankle bent with toes pointing away from the body, normal 0-50) - Left shoulder: 0-10 degrees (normal 0-180 degrees) - Left elbow: 0-10 degrees (normal 0-140 degrees) - Left wrist: 20-30 degrees (normal 0-80 degrees) - Left hand: positioned in flexion (bent) - Left hip: WFL - Left knee: 20-30 degrees - Left ankle: 0-10 degrees into plantarflexion The DOR reviewed Resident 62's Change in Condition JMA, dated 1/12/2022. The DOR stated Resident 62 had the following ROM in both arms and both legs: - Right shoulder: WFL - Right elbow: WFL - Right wrist: 20-80 degrees - Right hand: contractures of the ring fingers and little fingers - Right hip: WFL - Right knee: 20 degrees of motion - Right ankle: 0-10 degrees into plantarflexion - Left shoulder: WFL - Left elbow: WFL - Left wrist: 20-80 degrees - Left hand: contractures of the fingers - Left hip: WFL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 25 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 - Left knee: 10 degrees of motion Level of Harm - Minimal harm or potential for actual harm - Left ankle: 0-10 degrees into plantarflexion Residents Affected - Some The DOR stated Resident 62 did not receive another JMA after 1/12/2022 since Resident 62 was on hospice. The DOR stated the therapists did not perform any screening for ROM once a resident was placed on hospice services. During an observation and interview on 3/16/2023 at 5:46 PM in Resident 62's room, the DOR observed Resident 62's ROM. Resident 62 was lying in bed with the HOB elevated and wore a hospital gown. Resident 62 was awake, alert, and stated, I want therapy for all my problems because I can't move stuff. The DOR asked Resident 62 to move both arms. Resident 62 slightly lifted the right arm at the shoulder joint and slightly extended the right elbow. Resident 62 was unable to move the left arm. The DOR lifted the blankets to observe both of Resident 62's legs and stated, Oh my God. The DOR stated Resident 62 had contractures to both ankles into plantarflexion. The DOR walked out of Resident 62's room and stated Resident 62 declined since the last JMA on 1/12/2022. The DOR stated Resident 62 had increased contractures in both ankles, both wrists, and both hands/fingers. The DOR stated the DOR could not touch Resident 62 since Resident 62 was on hospice services. The DOR stated the facility discontinued RNA services when residents were placed on hospice. During an interview and record review on 3/17/2023 at 7:37 AM, the DOR compared Resident 62's JMA from 3/11/2021 and 1/12/2022. The DOR stated Resident 62 was discharged from PT and OT services on 4/2/2021 with recommendations for ROM with RNA and application of a left-hand splint. The DOR stated Resident 62's ROM in the left shoulder, left elbow, left wrist, and left hand improved on the JMA, dated 1/12/2022, because Resident 62 received RNA services for ROM and application of the left-hand splint. The DOR stated Resident 62 currently had contractures to both ankles, both wrists, and both hands. The DOR did not know the reason for Resident 62's decline in ROM and Resident 62's contracture development. During an interview on 3/17/2023 at 9:33 AM, the Hospice Certified Nursing Assistant (CHHA 1) stated Resident 62 received a bed bath, oral care, nail care, body lotion application, and perineal care (genital and rectal cleaning). CHHA 1 stated providing ROM was not part of the assignment. CHHA 1 stated CHHA 1 moved Resident 62's legs if Resident 62 did not complain of pain. CHHA 1 stated Resident 62 did lift the legs during care, and CHHA 1 would move Resident 62's legs if Resident 62 wanted to move them for comfort. CHHA 1 stated CHHA 1 did not move Resident 62's arms since Resident 62 was stiffer in both hands. During an interview on 3/17/2023 at 9:40 AM, Certified Nursing Assistant 7 (CNA 7) stated CNA 7 provided Resident 62 with ADL care, including dressing, bathing, changing the linen, changing positions every two hours, feeding, and oral care. CNA 7 stated Resident 62's wrists, hands, and ankles were bent and did not move. CNA 7 stated both of Resident 62's elbows and knees were very stiff. CNA 7 stated CNA 7 moved Resident 62's arms and legs during care but did not provide ROM. CNA 7 stated the RNAs provided ROM to the residents. CNA 7 stated Resident 62 wore a hospital gown because Resident 62 did not have any clothes. CNA 7 stated it would be difficult to dress Resident 62 in regular clothes because Resident 62 cannot bend both arms to get through sleeves which would likely hurt Resident 62 unintentionally. During a telephone interview on 3/17/2023 at 10:27 AM, Resident 62's Responsible Party (RRP 1) stated Resident 62 did not walk anymore but moved both arms and both legs upon admission to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 26 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility. RRP 1 stated the facility did not inform RRP 1 of Resident 62's ROM limitations in both arms and both legs. RRP 1 stated RRP 1 would never prevent the facility from performing exercises with Resident 62. RRP 1 stated Resident 62 used to exercise every day. During an observation and interview on 3/17/2023 at 11:31 AM in Resident 62's room, Resident 62 was sleeping with the HOB elevated and wearing a hospital gown. Both of Resident 62's wrists and hands were in a bent position while sleeping. CHHA 1 slightly bent the right elbow but stated CHHA 1 could not straighten Resident 62's right wrist and right fingers. CHHA 1 slightly lifted Resident 62's left arm at the shoulder joint and stated CHHA 1 could not bend the elbow because the bone felt very tight. CHHA 1 also stated CHHA 1 could not straighten Resident 62's left wrist and left fingers because they felt very contracted. CHHA 1 stated CHHA 1 has worked with Resident 62 for the past year and stated Resident 62 looked more fragile and developed more contractures. During an interview and record review on 3/17/2023 at 12:48 PM, the DON stated Resident 62 was originally admitted to the facility on [DATE] and remained at the facility since admission. The DON reviewed Resident 62's OT Progress and Discharge summary, dated [DATE], which indicated a recommendation for a RNP to apply the left-hand splint and provide PROM to both arms. The DON reviewed Resident 62's PT Progress and Discharge summary, dated [DATE], which indicated a recommendation to use a mechanical lift to transfer Resident 62 to a wheelchair and a RNP for ROM. The DON reviewed Resident 62's RNP documentation. The DON stated Resident 62 received RNA services from 4/6/2021 to 4/4/2022. The DON stated Resident 62's RNA task for PROM to both legs, PROM to both arms, and application of the inflatable left hand splint was discontinued on 4/5/2022. The DON reviewed Resident 62's clinical record, including but not limited to interdisciplinary team meetings and nursing progress notes. The DON stated Resident 62's clinical record did not indicate the reason for discontinuing Resident 62's RNA services. The DON stated the facility did not have any documented evidence Resident 62 received any PROM to both arms, PROM both legs, and splint application to either arm from 4/5/2022 to now, which the DON stated was a total of 11 months. A review of the facility's policy and procedure titled, Joint Mobility Screening and Assessment, revised on 11/2017, indicated a resident who enters the facility without limited range of motion and/or limited range of motion receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. The facility further indicated a Joint Mobility Assessment form will be completed by the rehabilitation staff upon initial assessment, annual assessment, and change of condition. A review of the facility's policy and procedure titled, Restorative Nursing Programs, revised on 9/2/2022, indicated it was the facility's policy to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The policy indicated Residents, as identified during the comprehensive assessment process, will receive services from restorative aids (RNAs) when they are assessed to have a need for restorative nursing services, which included providing PROM and splint or brace assistance. During an interview and record review on 3/17/2023 at 12:48 PM with the DON and DOR, the DOR stated Resident 62 did not receive another JMA after 1/12/2022 since Resident 62 was on hospice. Both the DON and DOR reviewed the facility's policies tilted, Joint Mobility Screening and Assessment and Restorative Nursing Programs. Both the DON and the DOR stated the facility's policies did not indicate residents placed on hospice care were excluded from receiving a JMA and RNP/RNA services. During a telephone interview on 3/17/2023 at 2:15 PM, the Hospice Registered Nurse (HRN 1) stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 27 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 63 had contractures to both wrists, both hands, and both feet. HRN 1 stated the hospice company only provided ROM during normal care to keep Resident 62 comfortable. HRN 1 stated the hospice staff did not provide ROM services. HRN 1 stated the hospice company would not prevent Resident 62 from receiving ROM exercises from the facility if the facility had a nursing program to perform ROM. During an interview on 3/17/2023 at 3:34 PM, the DOR stated contracture development should be avoided to prevent the development of pressure sores. The DOR stated it would be difficult to dress Resident 62 in regular clothes since the nurse would have to lift Resident 62's arms and bend the elbows. A review of the facility's policy titled, Prevention of Decline in Range of Motion, revised on 9/2/2022, indicated the facility shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. The policy further indicated the facility will provide intervention, exercises and/or therapy to maintain or improve range of motion. b. A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021 with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's care plan related to Resident 13's limited physical mobility, revised on 4/25/2022, indicated the following: 1. The goal was for Resident 13 to remain free of complications related to immobility, including contractures, thrombus formation (blood clot formation that limits the natural flow of blood), skin breakdown, and fall-related injury. 2. Interventions included ambulation (walking) with one staff required to assist Resident 13, provision of gentle ROM as tolerated with daily care, and assistance with mobility as needed. A review of Resident 13's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Treatment Encounter Note(s), dated 6/17/2022, indicated Physical Therapist 1 (PT 1) discussed with Resident 13 about Resident 13's discharge from PT. The PT Treatment Encounter Note indicated Resident 13 agreed to transition to the Restorative Nursing Program (RNP) for ambulation. A review of Resident 13's PT Discharge summary, dated [DATE], indicated Resident 13 was able to safely ambulate on level surfaces 60 feet using a two-wheeled walker with minimum assistance from the staff on 6/17/2022. The Discharge Summary indicated Resident 13 had good prognosis to maintain current level of functioning with consistent staff follow-through. A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), was able to understand others, and was able to express ideas and wants. The MDS indicated Resident 13 required limited one-person assistance and/or guided maneuvering of limbs with walking. The MDS indicated Resident 13's balance during transitions and walking was not steady and only able to stabilize with staff assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 28 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 13's Physician's Progress Notes, dated 1/6/2023, indicated Resident 13 had stasis dermatitis (skin inflammation due to fluid buildup related to poor blood circulation) in Resident 13's lower extremities (legs) and was receiving wound care due to a big toe wound. During an observation and interview on 3/14/2023 at 9:21 AM, Resident 13 stated the desire to participate in exercises because Resident 13 used to walk with a walker upon admission to the facility. Resident 13 was alert and oriented, with no evidence of pain or any distress while sitting in the wheelchair and received supplemental oxygen at 2 liters/minute. During an interview on 3/16/2023 at 8:42 AM, Certified Nursing Assistant 6 (CNA 6) stated CNA 6 did not know if Resident 13 could walk, because CNA 6 has not seen Resident 13 walk. During an interview on 3/15/2023 at 2:44 PM, the Director of Rehabilitation (DOR) stated the residents on RNP did not have any physician's orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a resident's care plan which created a RNP task. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings once per month. During an interview on 3/15/2023 at 2:52 PM, the DOR and MDSA stated a resident's RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a resident's ROM and to maintain a resident's functional status. D[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 29 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 48) with indwelling catheter (a tube inserted into the bladder used to drain urine from the bladder to the tube and the drainage bag) was assessed and monitored for cloudiness and presence of white sediments (substances or particles present in the urine) in the urine as indicated on the facility's policy and procedure titled, Indwelling Catheter Use and Removal, and Resident 48's care plan. This deficient practice had the potential to result in delay of care and treatment for a possible urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder) and/or dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in) for Resident 48. Findings: A review of Resident 48's admission Record indicated the facility admitted the resident on 9/24/2021, with diagnoses of benign prostatic hyperplasia (BPH - enlarge prostate gland that can cause uncomfortable urinary symptoms), acute kidney failure (an abrupt decline in renal function) and obstructive and reflux uropathy (a disorder involving the urinary tract). A review of Resident 48's care plan dated on 3/28/2022, indicated Resident 48 was at risk for UTI. The care plan goal indicated Resident 48 will show no signs and symptoms of infection. The interventions included for the staff to monitor the resident for signs and symptoms (s/sx) of UTI such as confusion, dark concentrate urine, and foul urine. A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/27/2023, indicated Resident 48 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 48 required extensive assistance with one person physical assist for bed mobility, transfer, dressing, and toilet use, and required total dependence (full staff assistance all the time) for bathing. A review of Resident 48's care plan revised on 3/14/2023, indicated Resident 48 had an indwelling suprapubic catheter (a hollow flexible tube that is inserted into the bladder through a cut in the tummy, used to drain urine from the bladder) related to obstructive uropathy secondary to BPH and was at risk for recurrence of catheter-associated urinary tract infection (CAUTI). The interventions included for the staff to record/report to the resident's physician s/sx of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. During a concurrent observation and interview with Registered Nurse 2 (RN 2), on 3/14/2023 at 9:34 am, Resident 48 was lying in bed with a suprapubic catheter draining cloudy urine with white sediments. RN 2 stated there should be no cloudiness and white sediments in the catheter tubing. RN 2 stated, cloudiness and sediments in the catheter tubing or urine could be signs of infection and needed to be reported to the resident's physician for a possible laboratory test. During a concurrent interview and review of Resident 48's medical record with RN 2, on 3/15/2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 30 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10:14 am, RN 2 stated there was no documentation that Resident 48 was monitored for signs and symptoms of UTI. During an interview with the Director of Nursing (DON) on 3/15/2023 at 12:48 pm, the DON stated, it was important to monitor Resident 48 for signs and symptoms of UTI for early detection and avoid complications of infection. A review of the facility's policy and procedures (P&P) titled, Indwelling Catheter Use and Removal, dated 9/2/2022, indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with professional standards of practice and resident care policies and procedures that include but are not limited to: ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting, and addressing such changes. The P&P indicated additional care practices include: recognition and assessment for complications and their causes, and maintaining a record of any catheter-related problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 31 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 29) reviewed for the use of oxygen was administered oxygen in a safe and sanitary condition in accordance with the standard of care and the facility's policy and procedure. Resident 29's oxygen tubing was not labeled with the date it was changed. Residents Affected - Few This deficient practice placed Resident 29 at risk for respiratory infection by possible contaminants (something that makes an item no longer suitable for use) in the tubing that was being used for an extended period of time. Findings: A review of Resident 29's admission Record indicated the facility initially admitted the resident on 11/16/2014, and readmitted the resident on 7/28/2020, with diagnoses that included obstructive sleep apnea (a condition in which individuals experience pauses in breathing during sleep associated with partial or complete closure of the throat or the upper airway), chronic atrial fibrillation (a condition in which the upper two chambers of the heart beat quickly and irregularly), and hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure). A review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/21/2023, indicated resident had the capacity to make self understood and understand others. The MDS indicated Resident 29 required extensive assistance from the staff for bed mobility, transfer, walking in room and corridor, dressing, toilet use, and personal hygiene, required limited assistance from the staff for locomotion on and off the unit, and required supervision for eating. The MDS indicated Resident 29 received oxygen therapy. A review of Resident 29's care plan dated 7/5/2022, indicated the resident had altered respiratory status/difficulty breathing related to the resident's obstructive sleep apnea. The interventions included for the staff to administer oxygen at two liters per minute (2 LPM) via nasal cannula (a flexible tubing with two prongs on one end placed under the nose to administer oxygen) as ordered. A review of Resident 29's physician order dated 7/26/2022, indicated for the resident to receive oxygen at 2 LPM via nasal cannula as needed for shortness of breath, and to maintain the resident's oxygen saturation (SpO2, the measurement of how much of oxygen is being carried by red blood cells) greater or equal to 92%. During an observation and concurrent interview with Resident 29 on 3/14/23 at 10:49 am, Resident 29 was in his room sitting on his wheelchair by his bed. Resident 29 was receiving oxygen at 2 LPM via nasal cannula. The nasal cannula was not labeled with the date it was changed. Resident 29 stated that he did not use the oxygen all the time and only used the oxygen when he was having breathing problems. During an interview with the Director of Staff Development (DSD) in Resident 29's room, on 3/14/23 at 10:52 am, the DSD confirmed that the resident's nasal cannula tubing was not labeled with the date it was changed. The DSD stated that the staff would change the tubing every week and the tubing needed to be dated so the staff would know when it was time to change the tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 32 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures titled, Oxygen Administration, revised on 9/2/2022, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goal and preferences. The policy indicated staff shall change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 33 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the routine pain medication was administered to one of 20 sampled residents (Resident 13) as ordered by the physician. Resident 13's Methadone (severe pain reliever) was not administered as ordered for six days in 1/2023 and 2/2023. Residents Affected - Few This deficient practice had the potential to cause ineffective pain management for Resident 13. Findings: A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021, with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's care plan for acute/chronic pain, revised on 4/25/2022, indicated the intervention to administer Methadone 30 milligrams as ordered. A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), but he was able to understand others and express ideas and wants. The MDS indicated Resident 13 required limited one-person assistance with bed mobility, transfer, walking, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated Resident 13's worst pain intensity over the last five days was 6. A review of Resident 13's Physician's Progress Notes, dated 1/6/2023, indicated Resident 13 had stasis dermatitis (skin inflammation due to fluid buildup related to poor blood circulation) in his lower extremities and was receiving wound care due to a big toe wound. A review of Resident 13's physician's orders from 1/2022 to 2/2023 indicated the order to give 15 milliliters of Methadone HCl solution 10 milligrams/5 milliliter orally in the morning for pain management, hold if respiratory rate less than 12, last reordered on 12/9/2022. A review of Resident 13's Medication Administration Records (MARs) from 1/2023 to 2/2023 indicated the following: 1. Methadone was coded as 6 on 1/8/2023, 1/9/2023, 1/10/2023, and 1/11/2023. 2. Methadone was not signed as administered by the licensed nurse on 2/27/2023 and coded 6 on 2/28/2023. During an observation and interview on 3/14/2023 at 9:21 am, Resident 13 stated his medication (unidentified) was missed about a month ago. Resident 13 was alert and oriented, with no evidence of pain or any distress while sitting in his wheelchair, and on supplemental oxygen at two liters per minute. During an interview on 3/16/2023 at 9:12 am, Licensed Vocational Nurse 3 (LVN 3) stated Resident 13 had a routine Methadone to be administered daily at 6 am as ordered by the physician. During a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 34 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concurrent review of the MAR for 2/2023, LVN 3 stated the medication was not administered on 2/27/2023 and 2/28/2023. LVN 3 stated there was no documented evidence on the progress notes or MAR indicating the reason for not administering the medication on the two dates. LVN 3 stated if the medication was held for any reason, it must be coded 2 with a reason documented on the resident's chart. LVN 3 stated medication administration must be coded accurately and timely to prevent possible missed medication or medication overdose. During an interview and concurrent review of Resident 13's MAR for 1/2022 on 3/16/2023 at 11:31 am, Registered Nurse 2 (RN 2) stated Methadone was not administered on 1/8/2023, 1/9/2023, 1/10/2023, and 1/11/2023. RN 2 stated there were no notes in 1/2023 indicating why Methadone was coded 6. RN 2 stated on 1/10/2023, the licensed nurse documented she called the pain management physician's office about the Methadone order and endorsed to the incoming shift. RN 2 stated the licensed nurse must call the physician or pharmacy about four to five days before the medication ran out to ensure continuity of care. RN 2 stated medication unavailability would lead to delayed treatment and inadequate pain management. A review of the facility's policy and procedures, titled Pain Management, dated 9/2/2022, indicated pain management must be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A review of the facility's policy and procedures, titled Medication Reordering, dated 9/2/2022, indicated the facility must utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. The policy indicated acquisition of medications must be completed in a timely manner to ensure medications are administered in a timely manner. The policy indicated each time a nurse is administering medications, the nurse must observe how many doses are left and reorder the medications when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 35 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to develop a policy that specified the time frames for acting upon the facility's consultant pharmacist's recommendation during the monthly regimen review (MRR, thorough evaluation of the resident's medication regimen to promote positive outcomes and minimize risks or adverse effects) for two of 20 sampled residents (Resident 9 and 54). a. For Resident 9, the facility staff did not act upon the MRR recommendation, dated 2/8/2023, to review with the physician the necessity of the routine and as needed (PRN) Melatonin (supplement to induce sleep) until 3/16/2023. b. For Resident 54, the facility staff did not act upon the MRR recommendation, dated 12/17/2022, to screen the resident for postural hypotension (form of low blood pressure that happens when standing after sitting or lying down). These deficient practices had the potential to cause a decline in the residents' physical and psychosocial well-being related to a delay in the necessary treatment and services. Cross Reference with F757 Findings: a. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder), hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure, major depressive disorder (persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (developed by individuals who experienced a shocking, scary, or dangerous event with symptoms like trouble sleeping and nightmares). A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 had sleeping problems nearly every day. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. A review of Resident 9's Consultant Pharmacist's MRR, dated 2/8/2023, indicated the following: Resident has an order for Melatonin 5 milligrams at bedtime for sleep. Please also review with MD if resident needs both routine and prn melatonin at bedtime. A review of Resident 9's active physician orders from 3/1/2023 through 3/17/2023 indicated the following orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 36 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 1. Give 1 tablet of Melatonin tablet 5 milligrams orally at bedtime for sleep. Level of Harm - Minimal harm or potential for actual harm 2. Give 1 tablet of Melatonin tablet 5 milligrams orally PRN at bedtime for supplement to regulate circadian rhythm, for inability to sleep. Residents Affected - Some During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 9:39 am, Licensed Vocational Nurse 3 (LVN 3) stated Resident 9 had active orders for routine and PRN Melatonin. LVN 3 stated the licensed nurse must clarify the order with the physician if it was necessary to administer two different medications to treat the inability to sleep. LVN 3 stated, if determined both medications were necessary, Resident 9 must either have the routine or as needed Melatonin order, and not both, to prevent overmedicating the resident. LVN 3 stated, if Melatonin was ordered to be administered routinely and was ineffective, the licensed nurse must call the physician to obtain any new orders. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 11:03 am, Registered Nurse 2 (RN 2) stated routine and PRN Melatonin must not be ordered at the same time due to possible overmedication. RN 2 stated the licensed nurse must call the physician to increase the routine Melatonin dosage if ineffective. RN 2 stated if she was assigned to follow through with the physician regarding a MRR recommendations, it must be done within 24 hours. RN 2 stated Resident 9's PRN Melatonin was discontinued on 3/16/2023. During an interview on 3/16/2023 at 12:20 pm, the Director of Nursing (DON) stated there was no specific time frame indicated in the facility's policy to act upon the pharmacy consultant's recommendations during the monthly MRR. The DON stated it could take between 30 to 45 days, but the registered nurse could prioritize and address the most important recommendation/s as soon as possible. A review of the facility's policy and procedures, titled Medication Regimen Review, dated 9/2/2022, indicated the monthly MRR includes a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The policy indicated the facility staff must act upon all recommendations according to procedures for addressing medication regimen review irregularities. b. A review of Resident 54's admission Record indicated the facility admitted Resident 54 on 9/13/2022, with diagnoses of orthostatic/postural hypotension (form of low blood pressure that happens when standing after sitting or lying down), history of falling, and unspecified dementia (memory loss which interferes with daily functioning). A review of a facility document titled, Consultant Pharmacist's Medication Regimen Review, dated 12/17/2022, completed by the facility's consultant pharmacist, indicated for the facility to review Resident 54 for falls. The consultant pharmacist recommendations included for the staff to screen Resident 54 for postural hypotension at lying and standing position. A review of Resident 54's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/6/2023, indicated Resident 54 had moderately impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 54 required limited assistance with one person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent review of Resident 54's medical record and interview with the Infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 37 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Preventionist Nurse (IPN) on 3/16/2023 at 9:12 am, the IPN stated there was no documentation that Resident 54 was screened or monitored for postural hypotension. The IPN stated, Resident 54's blood pressure needed to be monitored at lying and standing position to assess for fall risk and prevent fall. During an interview on 3/16/2023 at 12:20 pm, the Director of Nursing (DON) stated there was no specific time frame indicated in the facility policy to act upon the consultant pharmacist's recommendations during the monthly Medication Regimen Review. The DON stated it could take between 30 to 45 days, but the registered nurse could prioritize and address the most important recommendation/s as soon as possible. A review of the facility's policy and procedures (P&P) titled, Medication Regimen Review, dated 9/2/2022, indicated facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 38 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the medication regimen of two of 20 sampled residents (Residents 9 and 10) were free of any duplicate medication therapy and had adequate indications for its use. Residents Affected - Some a. For Resident 9, the facility failed to clarify with the physician whether the active orders for routine Melatonin (supplement to induce sleep) 5 milligrams at bedtime and as needed (PRN) Melatonin 5 milligrams at bedtime were both necessary in addition to an order for Trazodone 100 milligrams at bedtime, to address Resident 9's inability to sleep. b. For Resident 13, the facility failed to ensure PRN acetaminophen (used to treat minor aches and pain) 650 milligrams was only administered for mild pain as ordered, and PRN Percocet (controlled medication to treat moderate to severe pain) 5-325 milligrams was only administered for severe pain as ordered. These deficient practices had the potential to cause a decline in the residents' physical and psychosocial well-being. Cross Reference with F756 Findings: a. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder), hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure, major depressive disorder (persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (developed by individuals who experienced a shocking, scary, or dangerous event with symptoms like trouble sleeping and nightmares). A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 had sleeping problems nearly every day. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. A review of Resident 9's active physician orders from 3/1/2023 through 3/17/2023 indicated the following orders: 1. Give 1 tablet of Melatonin tablet 5 milligrams orally at bedtime for sleep. 2. Give 1 tablet of Melatonin tablet 5 milligrams orally PRN at bedtime for supplement to regulate circadian rhythm (natural internal process that regulates the sleep-wake cycle), for inability to sleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 39 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 3. Give Trazodone HCl 100 milligrams orally at bedtime for depression manifested by inability to sleep. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 9:39 am, Licensed Vocational Nurse 3 (LVN 3) stated the licensed nurse must clarify the order with the physician if it was necessary to administer two different medications to treat the inability to sleep. LVN 3 stated, if determined both medications were necessary, Resident 9 must either have the routine or as needed Melatonin order, and not both, to prevent overmedicating the resident. LVN 3 stated, if Melatonin was ordered to be administered routinely and was ineffective, the licensed nurse must call the physician to obtain any new orders. Residents Affected - Some During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 11:03 am, Registered Nurse 2 (RN 2) stated routine and PRN Melatonin must not be ordered at the same time due to possible overmedication. RN 2 stated the licensed nurse must call the physician to increase the routine Melatonin dosage if ineffective. RN 2 stated the licensed must call the physician to inform about Resident 9's condition and verify the Trazodone and Melatonin orders related to any possible drug-to-drug interactions. A review of the facility's policy and procedures titled, Consulting Physician/Practitioner Orders, dated 9/2/2022, indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner must call the attending physician to verify the order and document the verification order by entering the order, time, date and signature on the physician order sheet. The policy indicated if orders were received via telephone, the nurse must document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order, and call the attending physician to verify the order. b. A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021, with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), but he was able to understand others and express ideas and wants. The MDS indicated Resident 13 required limited one-person assistance with bed mobility, transfer, walking, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated Resident 13's worst pain intensity over the last 5 days was 6. A review of Resident 13's Physician's Progress Notes, dated 1/6/2023, indicated Resident 13 had stasis dermatitis (skin inflammation due to fluid buildup related to poor blood circulation) in his lower extremities and was receiving wound care due to a big toe wound. A review of Resident 13's physician's orders from 11/2022 to 3/2023 indicated the following active orders as of 3/17/2023: 1. Monitor for pain: 0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, 10 = very severe pain (ordered on 6/16/2021). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 40 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm 2. Give two tablets of acetaminophen tablet 325 milligrams orally every six hours PRN for mild pain, not to exceed three grams in 24 hours (ordered on 5/11/2021). 3. Give one tablet of Percocet tablet 5-325 milligram orally every six hours PRN for severe pain, not to exceed three grams in 24 hours (ordered on 4/7/2022). Residents Affected - Some During an interview and concurrent review of Resident 13's clinical records on 3/16/23 at 9:12 am, Licensed Vocational Nurse 3 (LVN 3) stated Resident 13 was given Tylenol as needed for mild pain or pain level of 1-3. LVN 3 stated Resident 13 was given Percocet as needed for severe pain or pain level of 7-10. LVN 3 stated if Resident 13 complained of moderate pain or pain level of 4-6, the physician must be notified to obtain a specific pain medication order for moderate pain to target the effectiveness of the pain medications without giving too much or too little. During an interview and concurrent review of Resident 13's clinical records on 1/2022 on 3/16/2023 at 11:31 am, Registered Nurse 2 (RN 2) stated she was not aware of the new pain scale (0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, 10 = very severe pain) indicated in Resident 13's physician orders. RN 2 stated she would call the physician to obtain/clarify the pain medication order for moderate pain to ensure all licensed nurses consistently administered Resident 13's pain medications as ordered. The MARs from 11/2022 to 3/2023 indicated the following: 1. On 11/2022 - Resident 13 had moderate level of pain (6-7) and Percocet 5-325 milligrams was administered on 11/4/2022, 11/9/2022, 11/11/2022 (x2), 11/12/2022, 11/13/2022, 11/14/2022, 11/16/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/23/2022, 11/24/2022, and 11/29/2022 (total of 14 times). 2. On 1/2023 - Resident 13 had moderate pain (7) and Percocet 5-325 milligrams was administered on 1/2/2023, 1/3/2023, and 1/24/2023 (total of three times). Resident 13 had moderate pain (5) and acetaminophen 650 milligrams was administered on 1/6/2023 (total of one time). 3. On 2/2023 - Resident had moderate level of pain (7) and Percocet 5-325 milligrams was administered on 2/24/2023 (total of one time). 4. On 3/2023 - Resident had moderate level of pain (7) and Percocet 5-325 milligrams was administered on 3/9/2023 and 3/14/2023 (total of 2 times). A review of the facility's policy and procedures titled, Pain Management, dated 9/2/2022, indicated pain management must be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy indicated the facility must use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 41 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 monitor and provide assistance for one of one sampled resident (Resident 14) reviewed for nutrition, to ensure the resident was able to use the special eating equipment and utensils provided to the resident when eating his meals. Residents Affected - Few This deficient practice placed Resident 14 at risk for malnutrition (lack of sufficient nutrients in the body) and further weight loss. Findings: A review of Resident 14's admission Record indicated the facility originally admitted the resident on 4/24/2019, and readmitted the resident on 1/4/2023, with diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar as a fuel and characterized by having high blood sugar level) with diabetic polyneuropathy (a complication of diabetes mellitus characterized by progressive damage of the nerve fibers usually of the arms and legs), muscle wasting and atrophy (thinning or loss of muscle tissue), and dysphagia (difficulty swallowing). A review of Resident 14's physician order dated 1/6/2023, indicated for the staff to provide the resident with built up utensils (eating utensils designed with molded plastic handles to assist individuals with limited or weakened grasping strength) and plate guard (prevent food from accidentally being pushed off the plate while eating) daily for all meals to promote self feeding tasks. A review of Resident 14's physician order dated 1/9/2023, indicated for the resident to have Controlled Carbohydrate - No Added Salt (CCHO - NAS) diet, mechanically altered texture (food are altered by whipping, blending, grinding, chopping, or mashing so food are easy to chew and swallow) and nectar consistency liquid (easily pourable and comparable to apricot nectar or thicker cream soups) for dysphagia. A review of Resident 14's dietary progress notes dated 1/9/2023, indicated Resident 14 was in the acute care hospital from [DATE] until 1/4/2023 because of respiratory failure (occurs when not enough oxygen passes from the lungs to the blood) and urinary tract infection (condition in which bacteria invade and grow in the urinary tract which includes the kidneys, ureters, bladder, and urethra). The dietary progress notes indicated Resident 14 had a 20 pounds (lbs.) or 10% weight loss in 30 days due to hospitalization. The dietary progress notes indicated Resident 14 had good oral intake and was fed by staff. A review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/11/2023, indicated resident had the ability to make self understood and understand others. The MDS indicated Resident 14 required extensive assistance from the staff for bed mobility, dressing, eating, and personal hygiene. A review of Resident 14's care plan dated 1/18/2023, indicated the resident had activities of daily living (ADLs) self-care performance deficit. The interventions included for one staff to provide extensive assistance with eating and to continue to assist the resident with ADLs daily. During a dining observation on 3/14/23 at 12:30 pm, Resident 14 was lying in his bed with the head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 42 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the bed elevated. Resident 14 was eating lunch by himself, and was using an adaptive spoon and fork and a plate guard to eat. There was no staff in the room to monitor and assist the resident to eat. Resident 14's right hand was shaking and the food on the spoon was falling off before the resident could put the spoon in his mouth. During an interview with Resident 14 on 3/14/23 at 12:39 pm, Resident 14 stated that he was done eating. Resident 14 stated that his food kept falling off the spoon and the resident could not see what he was eating. Resident 14 stated that he needed help with eating. During an interview with Certified Nursing Assistant 5 (CNA 5) in Resident 14's room, on 3/14/23 at 12:45 pm, CNA 5 stated he was assigned to Resident 14. CNA 5 stated Resident 14 did not need assistance with eating and the resident could eat by himself. CNA 5 checked the resident's food tray and stated that Resident 14 ate 20% of his food, almost nothing. A review of the facility's policy and procedures titled, Use of Assistive Devices, revised on 9/2/2022, indicated facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 43 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) to three of five residents (Resident 62, 66, and 1) receiving hospice care. The facility failed to: 1. Officially designate the facility's staff member responsible for coordinating hospice services in the facility's policy. 2. Ensure the facility's coordinator for hospice care coordinated and communicated with the hospice company to ensure the provision of hospice services. 3. Ensure the facility's licensed staff were aware of the facility's designated coordinator for hospice care. 4. Ensure the Hospice Certified Nursing Assistant (CHHA - nursing aide who are trained specifically for hospice care) provided timely care on designated dates and communicated the hospice visits with detailed notes in the residents' clinical record binder specifically for hospice care (hospice binder). These failures prevented Resident 66, 62, and 1 from receiving well-coordinated and comprehensive hospice services. Findings: A review of the facility's policy and procedures titled, Hospice Services Facility Agreement, revised on 9/2/2022, indicated it was the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The policy indicated the facility had designated (the Assistant Director of Nursing, or specify the member from the interdisciplinary team) to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff. During an interview on 3/15/2023 at 9:30 am, Registered Nurse 2 (RN 2) stated the facility did not have a designated contact person for hospice residents. RN 2 stated if the hospice staff had any concerns, additional physician's orders, or questions, then the hospice staff would contact the charge nurse or RN supervisor assigned to the specific hospice resident. During an interview on 3/16/2023 at 11:03 am, Licensed Vocational Nurse 2 (LVN 2) stated LVN 2 did not know who the hospice coordinator was for the facility. LVN 2 stated the hospice personnel alerted the charge nurse if they were in the facility for a resident. LVN 2 stated the facility's hospice coordinator was supposed to be ensuring the residents on hospice were receiving services according to the hospice contract, but LVN 2 did not know who the facility's hospice coordinator was. During an interview on 3/16/2023 at 11:35 am, LVN 1 stated any nursing supervisor could be the hospice coordinator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 44 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and record review on 3/16/2023 at 11:47 am, the Director of Nursing (DON) and the Director of Social Services (DSS) stated the hospice coordinator was the DON. The DON reviewed the facility's policy for hospice services and stated the facility did not designate a staff member in charge of coordinating hospice services in the facility's hospice policy. During a follow-up interview on 3/17/2023 at 11:49 am, the DON stated the DON was the official coordinator for hospice but delegated all the tasks related to hospice to the DSS since the DSS initiated hospice services. a. A review of Resident 66's admission Record indicated the facility originally admitted Resident 66 on 4/2/2021. Resident 66's diagnoses included alcoholic cirrhosis of liver (final phase of liver disease) with ascites (abdominal swelling caused by accumulation of fluid related to liver disease), acute respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), and acute ischemic heart disease (hardening of blood vessels preventing blood flow and oxygen to the heart). A review of Resident 66's census list (record of hospitalizations, room changes, and payer source changes) indicated Resident 66 was readmitted to the facility from the hospital on 2/2/2023. A review of Resident 66's admission Order, dated 2/2/2023, indicated Resident 62 was admitted to hospice care. A review of Resident 66's Physician's Certification for Hospice Benefit, dated 2/2/2023 to 4/2/2023, indicated Resident 66's primary hospice diagnosis included alcoholic cirrhosis of liver with ascites. A review of Resident 66's clinical record in Resident 66's hospice binder included a calendar, which indicated the dates hospice staff would provide services to Resident 66. A review of Resident 66's hospice calendar for 2/22/2023 to 2/28/2023 and 3/2023 did not clearly indicate the dates Resident 66 would receive CHHA services. Resident 66's hospice binder also included a Hospice Staff Sign-In Sheet. Resident 66's Hospice Staff Sign-In Sheet did not include a CHHA. Further review of Resident 66's hospice binder did not include CHHA communication sheets (note indicating the CHHA provision of care) from 2/2023 to 3/2023. The latest CHHA communication entry was dated on 12/22/2022. A review of Resident 66's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/1/2023, indicated Resident 66 had clear speech, clear expression of ideas and wants, clear understanding of verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 66 required extensive assistance (resident involved in activity with staff providing support) for bed mobility, transfers between surfaces, dressing, toileting, and hygiene. During an interview and record review on 3/16/2023 at 11:47 am, the DON stated Resident 66 had intermittently revoked hospice services to allow Resident 66 to be hospitalized for treatment. The DON stated Resident 66 was re-admitted to hospice care on 2/2/2023. The DON reviewed the Hospice Staff Sign-In Sheet, calendar, and CHHA notes. The DON stated the last CHHA note was dated in 12/2022. The DON stated there was no documented evidence the hospice CHHA provided care to Resident 66 in 2/2023 and 3/2023. b. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 45 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). Residents Affected - Some A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 12/15/2022, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 was totally dependent (full staff performance every time) for eating, dressing, and personal hygiene. The MDS indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's admission Order, dated 1/12/2022, indicated Resident 62 was admitted to hospice care with a diagnosis of Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). A review of Resident 62's clinical record in Resident 62's hospice binder included a calendar, which indicated the dates hospice staff would provide services to the Resident 62. Resident 62's hospice calendar indicated the CHHA was scheduled to provide care to Resident 62 on 2/7/2023, 2/9/2023, 2/14/2023, 2/16/2023, 2/21/2023, 2/23/2023, 2/28/2023, 3/7/2023, 3/9/2023, 3/14/2023, and 3/16/2023. Further review of Resident 62's hospice binder indicated the CHHA communication sheet (note indicating the CHHA provision of care) did not have any entries for 2/7/2023, 2/9/2023, 2/14/2023, and 3/7/2023. During an interview and record review on 3/16/2023 at 11:47 am, the DON reviewed Resident 62's hospice binder. The DON confirmed the hospice binder did not include a communication sheet for the provision of CHHA care to Resident 62 on 2/7/2023, 2/9/2023, 2/14/2023, and 3/17/2023. The DON stated the facility did not have documented evidence Resident 62 received CHHA care on 2/7/2023, 2/9/2023, 2/14/2023, and 3/17/2023. c. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 8/1/2008, and readmitted the resident on 2/15/2023. Resident 1's diagnoses included but was not limited to kidney failure, dysphagia (difficulty swallowing), attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), history of transient ischemic attack (brief stop of blood supply to the brain) and cerebral infarction (brain damage due to a loss of oxygen to the area) without residual deficits. A review of Resident 1's Physician's Certification for Hospice Benefit, dated 2/15/2023 to 5/15/2023, indicated Resident 1's primary hospice diagnosis was diffuse (spread out) traumatic brain injury (injury that affects how the brain works) with loss of consciousness of unspecified duration. A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 2/21/2023, indicated Resident 1 had unclear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 was totally dependent (full staff performance every time) for bed mobility, transfers between surfaces, dressing, eating, hygiene, toileting, and bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 46 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 1's clinical record in Resident 1's hospice binder included a calendar, which indicated the dates hospice staff would provide services to Resident 1. Resident 1's hospice calendar indicated the CHHA was scheduled to provide care to Resident 1 on 3/2/2023, 3/7/2023, 3/9/2023, 3/14/2023, and 3/16/2023. Further review of Resident 1's hospice binder indicated the CHHA communication sheet (note indicating the CHHA provision of care) did not have an entry for 3/2/2023. Resident 1's CHHA notes on 3/7/2023, 3/9/2023, and 3/14/2023 included a single, handwritten note for each date on the blank side of the CHHA communication sheet. During an interview and record review on 3/16/2023 at 11:47 am, the DON reviewed Resident 1's hospice binder. The DON confirmed the clinical record did not include a communication sheet for the provision of CHHA care to Resident 1 on 3/2/2023. The DON stated the facility did not have documented evidence Resident 62 received CHHA care on 3/2/2023. The DON also stated the CHHA notes on 3/7/2023, 3/9/2023, and 3/14/2023 were incomplete and did not indicate the care provided to Resident 1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 47 of 48 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain the physical space and equipment in the Rehabilitation Gym, including one box containing five lidocaine (medication for local pain relief) patches, two of two boxes of menthol (medication for minor muscle and joint aches and pain) patches, three of three packages with electrode (conductor through which electricity enters or leaves an object) preparation pads for skin preparation, and one container of ultrasound gel. This failure had the potential to prevent the provision of a functional and sanitary environment. Findings: During an observation on [DATE] at 9:05 am in the rehabilitation gym, a box with five unopened lidocaine pain relief patches expired on 11/2022. Two packages of unopened menthol medication patches expired on 8/2022. Three packages of electrode preparation pads for skin preparation expired on 6/2021. A container of ultrasound gel expired on [DATE]. During an observation and interview on [DATE] at 9:21 am in the rehabilitation gym, the Director of Rehabilitation (DOR) stated the rehabilitation department received a new ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) machine which was being calibrated (setting a measuring device to confirm with a reference standard). The DOR stated ultrasound gel was used as a conductor for ultrasound but would not be effective since the ultrasound gel expired on 3/2021. The DOR stated the electrode preparation pads were used to clean and prevent the skin from damage prior to applying electrodes on the skin. The DOR stated the electrode preparation pads were likely dry and unusable since they expired on 6/2021. The DOR observed the lidocaine and menthol patches and stated being unaware the patches were stored in the rehabilitation department. A review of the facility's policy and procedures titled, Rehab Equipment Maintenance & Safety, revised on [DATE], indicated preventative maintenance shall be performed on all rehab equipment to prolong the rehab equipment life and to ensure efficient operation and reliability of the equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 48 of 48