Health inspection·February 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced the resident's dignity and respect, by standing in front of the resident while assisting a meal for one of one sampled resident (Resident 49) in accordance with facility's policy on Promoting/Maintaining Resident Dignity During Mealtimes. This deficient practice had the potential to affect Resident 49's self-esteem and self-worth. Findings: During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 5/25/2018 with diagnoses that included cataract (clouding of the lens in the eye leading to a decrease in vision) and hypertensive retinopathy (damage of retinas [inner back lining of your eyes] from long-term high blood pressure). During a review of Resident 49's History and Physical (H&P), dated 10/31/2023, the H&P indicated Resident 49 did not have the capacity to understand and make decision. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/20/2023, the MDS indicated, Resident 49 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with eating. The MDS indicated Resident 49 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. During an observation on 2/13/2024 at 1:12 pm, Resident 49 was sitting in a wheelchair next to Resident 49's bed with uncovered hot plate on the food tray without staff assisting Resident 49 to eating. During an observation on 2/13/2024 at 1:14 pm, Certified Nurse Assistant 1 (CNA 1) stood in front of Resident 49 talking and assisting Resident 49 while eating. During a concurrent observation and interview on 2/13/2024 at 1:21 pm, with CNA 1, CNA 1 stated she needed to sit down next to Resident 49 and needed to be at eye level while assisting Resident 49 during mealtime to provide respect to Resident 49. During an interview on 2/15/2024 at 1:30 pm with Director of Nursing (DON), the DON stated, staff needed to sit and assist Resident 49 in a dignified manner to be able to see or observed Resident 49 Page 1 of 36 056466 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0550 while eating. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Promoting/Maintaining Resident Dignity During Mealtimes, revised on 12/19/2022, the P&P indicated, staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes and all staff will be seated, if possible, while feeding a resident. Residents Affected - Few 056466 Page 2 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 85's admission record, the record indicated the facility admitted Resident 85 on 1/11/20234 with diagnoses that included major depressive disorder (a feeling of severe sadness or hopelessness) and dementia (decline in mental ability severe enough to interfere with daily life). Residents Affected - Some During a review of Resident 85's History and Physical (H&P), dated 1/12/2024, the H&P indicated Resident 85 had fluctuating capacity to understand and make a decision. During a review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/15/2024, the MDS indicated, Resident 85's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 85 required moderate physical assistance with eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 85's Physician's Order, dated 1/25/2024, the order indicated to administer Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) tablet 7.5 milligram (mg) one tablet by mouth at bedtime for depression, manifested by poor intake. During a concurrent record review and interview on 2/16/2024 at 10:31 am with Licensed Vocational Nurse 1 (LVN 1), Resident 85's medical record was reviewed. The LVN 1 stated, Physician Documentation of Informed Consent for Remeron was not signed by Resident 85's physician. LVN 1 stated there was no documented evidence that informed consent was obtained for Resident 85 for the use of Remeron. LVN 1 stated, if it was not documented, it was not done. LVN 1 stated psychotropic medications needed to be discussed to the resident or residents responsible party to be aware of the side effects (harmful effects) of the medication. During a concurrent record review and interview on 2/16/2024 at 10:36 am with Registered Nurse 1 (RN 1), RN 1 stated Physician Documentation of Informed Consent for Resident 85's use of Remeron was not signed by the physician. RN 1 stated, the physician needed to call Resident 85's responsible party to obtain informed consent for the use of Remeron. RN 1 stated, there was no other clinical documentation that consent was obtained for Resident 85 who received Remeron. RN 1 stated, it was important to have an informed consent for residents receiving psychotropic medications because the risks and benefits needed to be discussed with Resident 85 or Resident 85's responsible party. During an interview on 2/16/2024 at 11:03 am with Resident 85's Responsible Party (RP 1), RP 1 stated, RP 1 did not receive a call from Resident 85's physician discussing and obtaining a consent for Remeron for Resident 85. RP 1 stated, RP 1 did not speak to Resident 85's doctor nor the facility licensed nurse to discuss the risk and benefits of Remeron on Resident 85. c. During a review of Resident 5's admission record, the record indicated the facility admitted Resident 5 on 4/2/2023 with diagnoses that included major depressive disorder (a feeling of severe sadness or hopelessness) and anxiety (emotion characterized by feelings of tension, worried thoughts, and physical changes). During a review of Resident 5's H&P dated 4/5/2023, the H&P indicated Resident 5 had the capacity to understand and make decision. 056466 Page 3 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 5's Physician's Order, dated 11/27/2023, the order indicated to administer Temazepam (used to treat insomnia [trouble with sleeping]) oral capsule 30 mg. one capsule by mouth at bedtime for insomnia manifested by inability to sleep. During a review of Resident 5's MDS, dated [DATE], the MDS indicated, Resident 5's cognition for daily decision making was intact. The MDS indicated Resident 5 required moderate physical assistance with toileting, shower, and upper body dressing. During a review of Resident 5's Physician's Order, dated 1/5/2023, the order indicated to administer Lexapro (antidepressant - a medication that change the way the brain regulate mood and behavior) one tablet 15 mg for depression manifested by verbalization of sadness over medical condition. During a concurrent record review and interview on 2/14/2024 at 2:07 pm with RN 1, RN 1 stated Physician Documentation of Informed Consent for Lexapro and Temazepam were not dated. RN 1 stated, RN1 would not be able to determine when the consent was obtained. RN 1 stated informed consent needed to be obtained when the medication was ordered, and medication dose was increased. RN 1 stated, there was no other clinical documentation that consent was initiated for Resident 5 to receive Lexapro and Temazepam. During a concurrent record review and interview on 2/15/2024 at 1:38 pm with the Director of Nursing (DON), the DON stated Physician Documentation of Informed Consent should be dated and signed by the physician. The DON stated it was important to have a valid informed consent for residents receiving psychotropic medications because the risks and benefits needed to be discussed with the residents or resident's responsible party. During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent, dated 12/19/2022, the P&P indicated, the facility will verify that informed consent has been obtained prior to any medical intervention or treatment is initiated. The P&P indicated the prescribing physician shall seek the consent of the resident to inform the resident's family of a prescription, order or increase of an order for psychotherapeutic medication within 48 hours of the order. Based on interview and record review the facility failed to obtain written informed consent for three of five sampled residents (Residents 81, 85 and 5) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. These deficient practices had a potential for Residents 81, 85 and 5 to not receive adequate information regarding the use of psychotropic medication, necessary to make an informed decision. Findings: a. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted on [DATE] with diagnoses that included hypertensive chronic kidney disease (high blood pressure caused by damaged kidneys), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), major depressive disorder or depression (a persistent sadness and loss of interest in activities that interferes with daily life) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). During a review of Resident 81's quarterly Minimum Data Set (MDS, a standardized resident 056466 Page 4 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 81 had severely impaired cognition (thinking), was taking an antidepressant (a high-risk medication used to treat depression that can cause harm if not taken correctly) and used a wheelchair for mobility. During a review of Resident 81's Physician Documentation of Informed Consent (PDIC). (undated), the PDIC indicated a physical restraint (all devices and practices used by the facility that restrict freedom of movement or normal access to one's body) order for half-length bed side rails to be in place and a psychoactive medication (a drug that affects brain function and mental processes) order for escitalopram oxalate (a medication used to treat depression) five milligrams (mg, a measure of solid weight. One thousandth of a gram) by mouth once daily with consent obtained from Resident 81's surrogate (an individual who makes decisions for someone who is no longer able to make their own health care decisions). The PDIC did not indicate a date when it was signed by the physician. During a review of Resident 81's Physician Documentation of Informed Consent (PDIC) (undated), the PDIC indicated a psychoactive medication order for trazodone HCL (a medication used to treat depression) 50 mg tablet at bedtime for depression and inability to sleep with consent obtained from Resident 81's surrogate. The PDIC did not indicate a date when it was signed by the physician. During a review of Resident 81's Physician Documentation of Informed Consent (PDIC) (undated), the PDIC indicated a psychoactive medication order for quetiapine fumarate (a medication used to treat symptoms of psychosis) 12.5 mg by mouth at bedtime for psychosis or verbal aggression toward others with consent obtained from Resident 81's surrogate. The PDIC did not indicate a date when it was signed by the physician. 056466 Page 5 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safety during self-administration of medications for one of one sampled resident (Resident 19.) Residents Affected - Few This deficient practice had the potential to result in unsafe medication use. Findings: During a review of Resident 19's admission Record, the admission record indicated the facility admitted the resident on 3/28/2022, with diagnoses that included diabetes mellitus (high blood sugar,) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning.) During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/1/2024, the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated the resident required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and dependent with toileting and showers. During an observation in Resident 19's room and interview with Resident 19 on 2/13/2024 at 10:52 am, there was one bottle of topical (applied to the skin) medication of fluocinolone acetonide on top of Resident 19's table. Resident 19 stated he had informed the licensed nurses (unidentified) who administer medications to him that he had been using the medicine for his scaly skin on his eyebrows and on top of his head. During an observation in Resident 19's room on 2/15/2024 at 11:20 am, there was one bottle of fluocinolone acetonide on the table in front of Resident 19. Licensed Vocational Nurse 4 (LVN 4) checked the bottle, which had an expiration date of July 2023. LVN 4 removed the medication from the table and stated she will get an order for the medication. During an interview on 2/16/2024 at 10:01 am, the Director of Nursing (DON) stated the family should not bring medications to the resident if not ordered by the physician. The DON stated it could have a negative effect to the resident. During a review of the facility's Policy and Procedure (P&P) titled Self-Administration of Medication dated 12/19/2022, the P&P indicated it was the policy of the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 056466 Page 6 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 83) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Call Lights: Accessibility and Timely Response and the resident's care plan. Residents Affected - Few This deficient practice had the potential for Resident 83 not to receive or received delayed care. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). During a review of Resident 83's untitled care plan initiated on 10/25/2023, the care plan indicated Resident 83 was at risk for falls and injuries. The care plan interventions indicated for nursing staff to place Resident 83's call light within reach and encourage the resident to use the call light for assistance as needed. The care plan indicated Resident 83 needed prompt response to all requests for assistance. During a review of Resident 83's Fall Risk Assessment (method of assessing a patient's likelihood of falling), dated 11/1/2023, the assessment indicated Resident 83 was assessed as at high risk for fall due to being disoriented, decreased muscular coordination, systolic blood pressure dropped between lying and standing, taking three or more medications currently and predisposing disease condition. During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated, Resident 83's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated, Resident 83 required total dependence with eating, oral hygiene, toileting, showering, upper or lower body dressing and personal hygiene. During a concurrent observation and interview on 2/13/2024 at 9:09 am, with Registered Nurse 1 (RN 1), Resident 83 was lying in bed with call pad on the right upper side of the bed. RN 1 stated Resident 83 was unable to reach the call pad. RN 1 stated Resident 83 was high risk for fall and the call pad needed to be within reach of Resident 83, to maintain the resident's safety. During an interview on 2/15/2024 at 1:19 pm, with Director of Nursing (DON), the DON stated, Resident 83's call light needed to be within reach of the resident at all times, in order to attend Resident 83's needs. The DON stated the call light was one of the modes of communication between the residents and staff and was the way of telling staff the resident needed assistance. During a record review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response revised on 12/19/2022, the P&P indicated, staff will ensure the call light 056466 Page 7 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0558 is within reach of the resident and secured as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056466 Page 8 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a care plan for one of one sampled resident (Resident 239) with edema (swelling caused by fluid retention) of the left leg. This deficient practice had the potential to result in worsening of edema for Resident 239. Cross Reference: F684 Findings: During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/26/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. Resident 239 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and sitting to lying and required maximal assistance (helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and toilet transfers. During an observation on 2/13/2024 at 11:45 am, Resident 239 was sitting in a wheelchair with both legs on the ground. Resident 239's left leg appeared swollen and red in color. During an observation on 2/15/2024 at 12:55 pm, Resident 239 was sitting in a wheelchair inside her room with left leg swollen and the resident's left leg was not elevated. During a concurrent observation and interview with the Director of Nursing (DON) on 2/16/2024 at 9:28 am, Resident 239 was sitting on a chair inside her room with both feet on the ground. The DON stated the left leg looked swollen and pinkish in color and moist. Resident 239 stated the left leg was moist because of water oozing due to the swelling. During a review of Resident 239's Skilled Evaluation Notes dated 2/13/2024, 2/24/2024 and 2/15/2024 on 2/16/2024 at 9:35 am, the nurse's notes did not indicate swelling on the left leg. During a concurrent interview with the DON, DON stated there were no notes indicating Resident 239's left leg edema was assessed and addressed. The DON stated based on the documentation, the DON was unable to determine when Resident 239's left leg edema started. The DON stated if Resident 239's left leg edema was identified, the nurses would make a plan of care for edema and the plan of care would include interventions such as monitoring the edema, measuring the edema, elevation of the affected part, medication regimen review and diet review. The DON stated measuring the edema was important to determine the baseline and if there was worsening or improvement of the edema. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Care Plans dated 12/29/2022, the P&P indicated the facility would develop and implement a comprehensive 056466 Page 9 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0656 Level of Harm - Minimal harm or potential for actual harm person-centered care plan for each resident, consistent with resident rights, that included 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. Residents Affected - Few 056466 Page 10 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

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 observation, interview, and record review the facility failed to provide the necessary care and services to assist resident's activities of daily living for three of three sampled residents (Residents 18, 48 and 49) by failing to: Residents Affected - Some a. Ensure Resident 18 was provided a communication device with the language that the resident understood. b. Ensure Resident 48 was provided a communication device with the language that the resident understood. These deficient practices had the potential for Residents 18 and 48 to not be able to express their needs and receive the necessary care and services. c. Assist Resident 49 who required assistance, encouragement and cueing with eating, during mealtime, in accordance with facility's policy titled Activities of Daily Living (ADL's). This deficient practice had the potential to result in a decline in Resident 49's activities of daily living, including the ability to eat which could lead to weight loss. Findings: a. During a review of the Resident 18's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hypertensive Chronic Kidney Disease (high blood pressure caused by damage to the kidneys), Type II Diabetes Mellitus (high levels of sugar in the blood because of a problem in the way the body regulates and uses sugar ), Unspecified Psychosis (symptoms that happen when a person is disconnected from reality) not due to a substance or known physiological condition, and Anxiety Disorder (involves a persistent feeling of anxiety or dread, which can interfere with daily life). During a review of Resident 18's care plan for communication problem related to language barrier, dated 9/14/2023 and revised on 9/19/2023, the care plan indicated Resident 18's primary language was Vietnamese but can make minimal needs known in English. The care plan also indicated Resident 18 had a diagnosis of Aphasia (a language disorder caused by damage in a specific area of the brain that controls language, causing the person unable to communicate). The goal of the care plan included for the resident to improve communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, and writing messages. The care plan intervention indicated Resident 18 preferred to communicate in Vietnamese language and required Vietnamese assistance in communication. The interventions listed also that Resident 18 required phone verbal translator assistive device to communicate, and to ensure availability and functioning of adaptive communication equipment. During a review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 1/2/2024, the MDS indicated Resident 18 had the ability to make self understood and understand others. The MDS indicated Resident 18 had clear speech, and adequate hearing with no difficulty in normal conversation, social interaction, or listening to television (TV). The MDS indicated 056466 Page 11 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 18 had range of motion limitations on both lower extremities and dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 18 had frequent urinary incontinence. During a review Resident 18's History & Physical (H&P) dated 1/16/2024, the H&P indicated Resident 18 had the capacity to understand and make decisions. During observation of Resident 18 and concurrent interview with Registered Nurse 1 (RN 1) on 2/13/24 at 10:43 a.m., Resident 18 was observed lying in bed, awake, with call light within reach. RN 1 ask how Resident 18 was and Resident 18 answered RN1 in Vietnamese language, and RN 1 could not figure out what Resident 18 said or what Resident 18 needed. RN 1 the facility used a phone translator to communicate with non-English speaking resident. RN 1 went to the nurse station and came back to Resident 18's room with the phone translator. RN 1 spoke on the phone translator to communicate with Resident 18 but there was no translation coming out of the phone. RN 1 tried several times to communicate with Resident 18 through the phone translator but was unable to, because no sound was coming out of the phone. RN 1 stated the facility had staff who speaks Vietnamese and could translate what Resident 18 tried to say. RN 1 stated the phone translator needed to be in good working condition and functional, because the staff who speak Vietnamese were not always available. During a review of the facility's Policy and Procedure (P&P) titled Effective Communication, revised on 7/17/2023, the P&P indicated it is the facility's policy to accommodate needs when communicating with residents who have difficulties with communication to promote dignity, understanding, and safety. The policy indicated that direct care staff will be educated on effective communication that reflects the needs of the resident population and needs of the staff and correspond with the Facility Assessment. The policy also indicated that staff would communicate with the resident using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible. b. During a review of Resident 48's admission Record, the admission record indicated the facility admitted the resident on 1/25/2023, with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). During a review of Resident 48's MDS dated [DATE], the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 48 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort,) for rolling left and right, sitting to lying, toileting and showers. During a concurrent observation and interview on 2/13/2024 at 11:35 am, Registered Nurse 1 (RN 1) attempted to use the language translator to speak with Resident 48, the resident shook her head and spoke in her language. The translator failed to translate what Resident 48 said. RN 1 looked for the communication tool to communicate with Resident 48 and found it inside Resident 48's drawer inside her room. RN 1 stated the communication tool was in Vietnamese and not in Mandarin. RN 1 stated they could not use the communication tool to communicate with Resident 48. During an interview on 2/14/2024 at 2:05 pm, Occupational Therapist (OTR) stated Resident 48 spoke Mandarin. OTR stated there were two mandarin speaking staff at the facility and would usually work Monday to Friday from 9:00 am to 5:00 pm. During a review of the facility's Policy and Procedure (P&P) titled Effective Communication dated 056466 Page 12 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7/17/2023, the P&P indicated effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand. c. During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 5/25/2018 with diagnoses that included cataract (clouding of the lens in the eye leading to a decrease in vision) and hypertensive retinopathy (damage of retinas [inner back lining of your eyes] from long-term high blood pressure). During a review of Resident 49's Nutrition Progress Notes dated 3/1/2023 at 3:08 pm, the notes indicated staff needed to encourage Resident 49 during meals and supplement intake. During a review of Resident 49's History and Physical (H&P), dated 10/31/2023, the H&P indicated Resident 49 did not have the capacity to understand and make decision. During a review of Resident 49's untitled care plan revised on 12/18/2023, the care plan indicated Resident 49 had nutritional problem. The care plan indicated Resident 49 needed assistance with personal care. The care plan interventions indicated for nursing staff to encourage Resident 49 to consume at least 60 percent (%) of meals. The care plan interventions indicated Resident 49 needed feeding assistance program for lunch by Certified Nurse Assistant (CNA). During a review of Resident 49's MDS dated [DATE], the MDS indicated, Resident 49 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with eating. The MDS indicated, Resident 49 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. During an observation on, 2/13/2024 at 9:33 am, Resident 49 was asleep, seated upright in bed. Resident 49's breakfast tray was in front of the resident with uncovered plate containing breakfast of pureed egg, juice, milk, and pancake. Resident 49 ate 20% of the meal. There was no staff observed assisting or encouraging Resident 49 to eat or drink. During a concurrent observation and interview on 2/13/2024 at 9:35 am, with Registered Nurse 1 (RN 1), RN 1 stated, Resident 49 took a long time to eat and did not need assistance during mealtime. RN 1 stated breakfast was served at 7:30 am. During a concurrent interview and record review with RN 1, on 2/13/2024 at 10:29 am, Resident 49's medical records were reviewed. RN 1 stated, Resident 49 needed supervision, assistance, verbal cues from staff during eating. RN 1 stated there was no staff assisting Resident 49 during breakfast and that was the reason why Resident 49 did not finish eating breakfast. RN 1 stated, if Resident 49 was not supervised during mealtime, Resident 49's food would get cold, and the resident would not be getting enough nutrition that could lead to weight loss. During a concurrent observation and interview on 2/13/2024 at 1:21 pm, with CNA 1, CNA 1 stated Resident 49 was on feeding assistance program to remind and encourage Resident 49 to eat. CNA 1 stated, CNA 1 needed to stay and check Resident 49 and give verbal cues during mealtime until Resident 49 consumed the meal. During an interview on 2/15/2024 at 1:23 pm, with the Director of Nursing (DON), the DON stated, 056466 Page 13 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0676 staff needed to be with Resident 49 during mealtime to encourage the resident to eat. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL's), revised on 12/19/2022, the P&P indicated, care and services may consist of the following activities of daily living: eating to include meals and snacks. The P&P indicated a resident who is unable to carry out activities of daily lining will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Residents Affected - Some 056466 Page 14 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 set up the lunch tray for one of one sampled resident (Resident 44) with severely impaired vision. Residents Affected - Few This failure had the potential to result in Resident 44 losing weight and becoming dehydrated (when the body does not have enough fluid to function properly) due to the inability to feed himself. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (when the body's metabolism causes brain dysfunction), blindness in one eye, low vision in the other eye, and glaucoma (a group of eye conditions that cause blindness). During a review of Resident 44's Care Plan, revised on 10/7/2022, the care plan indicated Resident 44 had an activity of daily living (ADL) self-care performance deficit related to his conditions and required supervision by one staff member for eating. During a review of Resident 44's Care Plan, revised on 8/16/2023, the care plan indicated Resident 44 had impaired visual function related to glaucoma, cataracts (cloudiness on the eye lens that obstructs vision) and diabetic retinopathy (an eye disease from uncontrolled sugar that can cause blindness) and would bump into objects while in his wheelchair, grab for drinks that were not there and had a history of multiple falls related to his impaired vision. During a review of Resident 44's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 44 had moderately impaired cognition (thinking), had highly impaired vision (eyes are able to follow an object, but identifying an object is questionable) in adequate lighting, and needed substantial or maximal assistance during eating when the meal was placed before the resident. During a review of Resident 44's Care Plan, revised on 2/13/2024, the care plan indicated Resident 44 had potential nutritional problems and malnutrition related to his multiple diseases and required assistance at meals as needed. During a concurrent observation and interview on 2/13/2024 at 1:09 pm with Resident 44 in Resident 44's room, Resident 44 was seated in his wheelchair with the bedside table end facing the resident with a covered lunch tray that was not within reach. Resident 44 stated he had poor vision and needed assistance to eat lunch. During a concurrent observation and interview on 2/13/2024 at 1:13 pm with Licensed Vocational Nurse 2 (LVN 2) in Resident 44's room, Resident 44 was seated in his wheelchair with the bedside table end facing the resident with a covered lunch tray that was not within reach. LVN 2 stated, that is not considered a proper meal setup and the nursing assistant should have provided the resident with feeding assistance. LVN 2 further stated it is important to help feed him for nutritional and quality of life purposes. During a review of Resident 44's Breakfast, Lunch, and Dinner Meal Tickets (food planned for that 056466 Page 15 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0677 day's mealtime), dated 2/14/2024, the breakfast, lunch, and dinner meal tickets indicated Resident 44's feeding ability required a partial assist (setup of the meal) and supervision during the meal. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056466 Page 16 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 73's admission Record, the admission record indicated Resident 73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Type II Diabetes Mellitus ( a condition that happens because of a problem in the way the body regulates and uses) with hyperglycemia (high blood sugar), Cerebral Palsy (a group of lifelong conditions that affect movement and co-ordination), and Quadriplegia (paralysis that affects all of a person's limbs and body from the neck down). Residents Affected - Some During a review of Resident 73's History and Physical, dated 4/16/2023, the H&P indicated Resident 73 does not have the capacity to understand and make decisions. During a review of Resident 73's Minimum Data Set (MDS, a standardized assessment and care panning tool), dated 12/12/2023, the MDS indicated Resident 73 does not have the ability to make self understood and understand others. The MDS indicated Resident 73's cognitive (ability to understand) skills for daily decision making were severely impaired and Resident 73 was dependent on staff for his functional abilities (activities of daily living). The MDS indicated Resident 73 was always incontinent of bowel and bladder. The MDS also indicated Resident 73 had a diagnosis of Diabetes Mellitus. During a review of Resident 73's undated care plan for Type II Diabetes Mellitus with Hyperglycemia, the care plan indicated a goal for Resident 73 to be free of any signs and symptoms of hyperglycemia. The care plan interventions included to monitor, document, report as needed (PRN) any signs and symptoms of hyperglycemia. During a review of Resident 73's Physician Orders indicated a stat (now or immediately) order, dated 2/16/2024, for Complete Blood Count (CBC- a blood test that measures many different parts and features of the blood), Comprehensive Metabolic Panel (CMP- a blood test that gives doctors information about the body's fluid balance, levels of electrolytes and how well the kidneys and liver are working), and HgbA1C (blood test that shows the average blood sugar [glucose] level over the past two to three months). There was no other active blood sugar monitoring ordered or medication ordered for Resident 73's Diabetes Mellitus. During a review of Resident 73's laboratory blood test results, the results indicated Resident 73's blood Glucose level was 181 milligrams/dilution (mg/dl) on 1/29/2024; 121 mg/dl on 12/22/2023; 160 mg/dl on 12/14/2023 and 201 mg/dl on 12/5/2023. The reference (normal) level for glucose level was 65 - 99 mg/dl. Resident 73's HgbA1C laboratory blood test result on 12/5/2023 was 6.8 percent (%). The reference level for HgbA1C was less than (<) 6.0%. During a review of Resident 73's Medication Administration Record (MAR) for the month of December 2023, January 2024, and February 2024, the MAR indicated Resident 73 did not have any medication that was administered for Resident 73's Diabetes Mellitus and Hyperglycemia. During an interview with Registered Nurse 1 (RN 1) on 2/16/2024 at 12:26 p.m., after reviewing the nurse's progress notes and physician's orders for Resident 73, RN 1 stated there was no documentation that Resident 73's 201 mg/dl blood Glucose level on 12/5/2023 was addressed. RN1 stated Resident 73 needed to be assessed for signs and symptoms of hyperglycemia and the physician needed to be notified. RN 1 stated that the documentation on the progress notes needed to have specific documentation that Resident 73 was assessed for hyperglycemia and that the physician was notified specifically 056466 Page 17 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0684 about the high glucose level of Resident 73. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide needed care and services to two of two sampled residents (Residents 239 and 73) that will meet each resident's physical, mental, and psychological needs, when the facility failed to: Residents Affected - Some a. Address Resident 239's edema of the left leg by elevating the leg or provided measures to elevate the affected leg. b. Address elevated blood glucose levels for Resident 73. These deficient practices had the potential to result in negative outcome to Residents 239 and 73, affecting the residents' quality of life. Findings: a. During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/26/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. Resident 239 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and sitting to lying and required maximal assistance (helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and toilet transfers. During an observation on 2/13/2024 at 11:45 am, Resident 239 was sitting in a wheelchair with both legs on the ground. Resident 239's left leg appeared swollen and red in color. During an observation on 2/15/2024 at 12:55 pm, Resident 239 was sitting in a wheelchair inside her room with left leg swollen and the resident's left leg was not elevated. During a review of Resident 239's Skilled Evaluation Notes dated 2/13/2024, 2/24/2024 and 2/15/2024 on 2/16/2024 at 9:35 am, the nurse's notes did not indicate swelling on the left leg. During a concurrent interview with the DON, DON stated there were no notes indicating Resident 239's left leg edema was assessed and addressed. The DON stated based on the documentation, the DON was unable to determine when Resident 239's left leg edema started. During a review of the facility's Policies and Procedures (P&P), there was no P&P for the management of edema. 056466 Page 18 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 11's admission record, the admission record indicated Resident 11 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness or the inability to move on one side of the body), pressure ulcer ( lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) of the sacral region stage 4 (very deep, big, and painful open sore caused by pressure at the bottom of the spine), Type II Diabetes Mellitus (high levels of sugar in the blood because of a problem in the way the body regulates and uses sugar) with Hyperglycemia (high blood glucose level), and Morbid (severe) Obesity (a complex disease involving having too much body fat). Residents Affected - Some During a review of Resident 11's care plan for stage 4 pressure injury on the Sacro Coccyx (tailbone), dated 7/19/2023, the care plan indicated a goal for Resident 11's wound to show signs of improvement. The care plan interventions included to monitor placement and function of the LAL mattress. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had clear speech and had the ability to make self understood and understand others. The MDS indicated Resident 11 was dependent on staff for toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, and mobility. The MDS indicated Resident 11 required substantial/maximal assistance for oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 11 was at risk for developing pressure ulcers, and at the time of the MDS assessment, Resident 11 had one stage 3 (ulcer extending through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) and one stage 4 pressure ulcer. The MDS indicated Resident 11 has a pressure reducing device for his bed. During a review of Resident 11's History and Physical (H&P) dated 1/24/2024, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Physician's Order Summary, the summary indicated an order dated 1/25/2024 for a Low Air Loss Mattress (LAL mattress-- tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float) for skin management and to check setting and function every shift. During a review of Resident 11's Weights and Vitals form, the form indicated the resident's weight on 2/5/2024 at 9:57 a.m. was 248.0 pounds (lbs.). During an observation of Resident 11 on 2/13/2024 at 12:41 p.m., Resident 11 was observed in bed, awake, and alert. Resident 11's LAL mattress was set on 160. During an interview with the Treatment Nurse (TXN 1) on 2/14/2024 at 3:38 p.m., TXN 1 verified the setting for Resident 11's LAL mattress was set at 160. TXN 1 stated the setting was according to the Resident 11's latest weight. TXN 1 verified Resident 11's weight in the resident's medical record and stated Resident 11's latest weight was 248 lbs. and not 160 lbs. TXN 1 stated that he made a mistake and thought the resident's weight was 148 lbs. TXN1 stated Resident 11's LAL mattress setting needed to be at 240 which was the closest setting to the resident's weight. TXN 1 stated it was important for the setting to be accurate because if it was too soft, the pressure would not be appropriate for Resident 11. 056466 Page 19 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) was set accurately for two of three sampled residents (Residents 84 and 11) reviewed for pressure ulcers (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). This failure had the potential for Resident 84's and Resident 11's skin conditions to worsen or develop further skin breakdown. Findings: a. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included necrotizing fasciitis (a bacterial infection that cause skin, tissue and muscle death), type II diabetes (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel) with skin ulcer (an open sore caused by poor blood flow) and methicillin resistant staphylococcus aureus infection (an infection caused by a bacteria that is resistant to antibiotics). During a review of Resident 84's care plan revised on 11/17/2023, the care plan indicated that Resident 84 had potential/actual impairment to skin integrity and was at high risk for further development of skin problems, nonhealing, infection and or deterioration of wounds. During a review of Resident 84's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 84 had severely impaired cognition (thinking), was completely dependent on helpers to change position in bed, had five venous and arterial ulcers present, a diabetic foot ulcer (an open sore on the foot caused by poor circulation from diabetes), a surgical wound, moisture associated skin damage (skin irritation or damage caused by prolonged exposure to moisture) and had a pressure reducing device for his bed as one of the treatments. During a review of Resident 84's Order Summary Report dated 1/30/2024, the order summary report indicated Resident 84 had an active order for a LAL mattress (LAL, a pressure reducing bed that alternates pressure to help heal and prevent skin breakdown) for skin management and settings and functions were to be checked every shift. During a review of Resident 84's Skin Only Evaluation dated 2/7/2024, the evaluation indicated the interventions for Resident 84's documented pressure ulcer was to provide skin care per facility guidelines and wound care per treatment order. During a concurrent observation and interview on 2/13/2024 at 10:02 am with the Treatment Nurse (TN), in Resident 84's room, the low air loss mattress control unit was on the static (firm pressure) setting while the resident was lying in bed. TN stated Resident 84 was on the LAL mattress to relieve pressure on a surgical wound located on his back. TN further stated the static setting means the bed won't move and it shouldn't be on that setting. During a review of Proactive medical products: Operation Manual for Protekt Aire 2000, (undated), the manual indicated it provides low air loss pressure redistribution therapy, but when in static mode it will provide a firm surface. 056466 Page 20 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0686 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, revised 9/12/2023, indicated, the facility would provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries by providing appropriate, pressure-redistributing, support surfaces as an intervention for prevention and to promote healing. Residents Affected - Some 056466 Page 21 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the bed was at the lowest position for two of six sampled residents (Residents 39 and 69) who were assessed as high risk for falls. This deficient practice had the potential to result in injury secondary to falls. Findings: During a review of Resident 39's admission Record, the admission record indicated the facility admitted the resident on 8/17/2018, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and hemiplegia and hemiparesis (weakness and paralysis on one side of the body.) During a review of Resident 39's Fall Risk assessment dated [DATE], the assessment indicated the resident was at risk for falls due to intermittent confusion, required assistance with elimination, poor vision, balance problem while standing and required the use of assistive devices. During a review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/19/2023, the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 39 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half effort) for rolling left to right, sit to lying mobility and dependent with toileting and showering needs. During an observation on 2/14/2024 at 10:00 am, with the MDS Nurse. Resident 39's bed was 28 inches from the floor. The MDS Nurse maneuvered the bed to its lowest position (when the bed stops moving down while pressing the bed control) and the top of the mattress was 21 inches from the floor. During a concurrent interview, the MDS Nurse stated the bed needed to be low so the risk for injury will be lower in case of a fall. During a review of Resident 69's admission Record, the admission record indicated the facility admitted the resident on 11/14/2023, with diagnoses that included dementia and a history of falling. During a review of Resident 69's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated Resident 69 was dependent with rolling left to right, sit to lying, lying to sitting sit to stand and chair/bed-to-chair transfers, toileting, and showers. During an observation on 2/15/24 at 8:20 am, Resident 69's bed was not at its lowest position, the top of the mattress was at upper thigh level. The RN Supervisor maneuvered the bed to its lowest position and the top of the mattress was at the level above the knee. During a concurrent interview, the RN Supervisor stated the bed needed to be at the lowest position because the risk for injury would be lessened if the bed was low. During a review of the facility's Policy and Procedure (P&P) titled Fall Prevention Program dated 12/28/2023, the P&P indicated the resident will be assessed for fall risk and will receive care and services. 056466 Page 22 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

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 the nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) was placed properly by placing both nasal prongs in the resident's nostrils for one of one sampled resident (Resident 83) in accordance with the facility's policy titled Oxygen Concentrator. Residents Affected - Few This deficient practice placed Residents 83 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues). Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included acute respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) unspecified with hypoxia or hypercapnia (high levels of carbon dioxide [waste product that the body gets rid of when a person exhales]). During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Physician Order's, dated 11/15/2023, the order indicated Resident 83 needed to receive oxygen at four (4) liters per minute (L/min) via nasal cannula and to maintain resident's oxygen saturation (amount of oxygen carried in blood) above or equal to 92 percent (%) every shift. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated, Resident 83's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 83 required total dependence with eating, oral hygiene, toileting, shower, upper or lower body dressing and personal hygiene. During an observation on 2/13/2024 at 9:04 am, with Registered Nurse 1 (RN 1), Resident 83 was observed awake, lying in bed. Resident 83's nasal cannula was observed with only one prong in resident's right nostril and the left prong was out of the nostrils. The nasal cannula was not delivering oxygen to both nostrils. RN 1 stated the nasal cannula needed to be inside both nostrils of Resident 83 to receive the desired oxygen needed. During an interview on 2/15/2024 at 1:20 pm with the facility's DON, the DON stated the nasal cannula needed to be placed inside Resident 83's both nostrils when in use to ensure the desired oxygen needed by Resident 83 was administered as ordered. During a record review of the facility's Policy and Procedure (P&P) titled, Oxygen Concentrator, revised on 12/19/2022, the P&P indicated to place the nasal cannula on the resident, adjusting to fit resident and achieve comfort. 056466 Page 23 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 conduct reassessment after a routine pain medication was administered for one of two sampled residents (Resident 239.) Residents Affected - Few This deficient practice resulted in Resident 239 to continue to experience pain, affecting the resident's quality of life. Findings: During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/25/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. The MDS indicated Resident 239 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and sitting to lying and required maximal assistance (helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and toilet transfers. During a review of Resident 239's risk for pain care plan, initiated on 1/11/2024, the care plan indicated to evaluate effectiveness of pain interventions (30 minutes after medication administration). During an observation on 2/14/2024 at 11:25 am, Resident 239 informed the staff she was in pain at 9/10 level on pain scale (0=no pain; 10=worst pain). During a medication pass administration observation on 2/15/2024 at 9:16 am, Licensed Vocational Nurse 4 assessed Resident 239's pain to be 10/10, described as burning pain on both legs. Resident 239 stated she was shaking because of the pain. LVN 4 administered Lyrica 100 milligrams (mg) and Morphine Sulfate (MS Contin)15 mg. LVN 4 informed Resident 239 Lyrica was for neuropathic pain. During an interview on 2/15/2024 at 11:10 am, Resident 239 stated she was still experiencing pain at 8/10 on her legs. Resident 239 stated LVN 4 did not come back to reassess her pain level after giving her the scheduled medications. During an interview on 2/15/2024 at 11:15 am, LVN 4 stated she did not go back to reassess Resident 239's pain level. LVN 4 stated if Resident 239 still had pain, LVN 4 could try non-pharmacological interventions such as repositioning, distractions with TV. LVN 4 stated she did not do the non-pharmacological interventions since she failed to go back to reassess Resident 239. During a review of the facility's Policy and Procedure (P&P) titled Pain Management, dated 12/19/2022, the P&P indicated the facility staff will reassess resident's pain management regularly for effectiveness and/or adverse consequences. 056466 Page 24 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Attempt appropriate alternatives prior to installing side (bed) rail for two of six sampled residents (Residents 65 and 85). 2. Follow the physician's order for bilateral (on both sides) side rails with length to be at one quarter (rails at the head of the bed that are less restrictive for movement) use as an enabler (bedrails used to aid movement) for one of six sampled residents (Resident 78). These deficient practices had the potential to present a safety hazard and risk of entrapment to Residents 65, 85 and 78. Findings: 1.a. During a review of Resident 65's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2022 and readmitted on [DATE] with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time. During a review of Resident 65's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/26/2024, the MDS indicated the resident had severe cognitive (ability to understand) impairment. The MDS indicated Resident 65 was dependent with all activities of daily living. During a review of Resident 65's document titled Bedrails Assessment dated 1/4/2024, the assessment indicated to provide visual and verbal reminders to use the call light. The assessment indicated the reason why alternative was ineffective was due to right sided weakness. During an observation on 2/13/2024 at 11:27 am, Resident 65 was lying in bed, awake, with bilateral side rails up. Resident 65 was moving her left arm and her right arm was bent towards the left side of her chest. During a concurrent record review and interview with the MDS Nurse on 2/14/24 at 3:10 pm, bedrails assessment was reviewed. The MDS Nurse stated the bedrails assessment indicated no appropriate alternatives attempted prior to the use of the side rails. 1.b. During a review of Resident 85's admission Record, the admission Record indicated the facility admitted the resident on 1/11/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and history of falling. During a review of Resident 85's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated the resident required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with rolling left to right, sit to lying and lying to sitting on the side of the bed mobility and toileting needs. 056466 Page 25 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0700 During an observation on 2/14/2024 at 8:30 am, Resident 85 was awake in bed and both side rails were up. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/14/2023 at 8:59 am, Resident 85 stated he remembered he had a history of a fall but could not remember when it occurred. Resident 85 pointed to the siderail and stated the siderail was the problem; because of the siderail he had to move down the bed, and he fell. Resident 85 stated he did not have any injury from the fall. Residents Affected - Some During a review of the Resident 85's document titled Bedrails Assessment dated 1/11/2024, the assessment indicated the following alternatives were attempted: lowered the bed to the floor, provided frequent staff monitoring, and provided visual and verbal reminders to use the call light. The assessment indicated the reason why the alternatives were ineffective was due to cognitive and physical mobility deficit due to left above the knee amputation and dementia. During an interview on 2/14/2024 at 2:45 pm, the MDS Nurse stated the indicated reason why the alternatives failed did not explain how the alternatives failed. The MDS Nurse stated there were no other alternatives attempted after the low bed failed. During an interview on 2/16/2024 at 8:52 am, the Director of Nursing (DON) stated the use of siderails would put the resident at risk for entrapment and injuries. During a review of the facility's Policy and Procedure (P&P) titled Proper Use of Bed Rails dated 12/19/2022, the P&P indicated to utilize a person - centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. The P&P indicated alternatives include, but are not limited to; roll guards, foam bumpers, lowering the bed and concave mattress. If no appropriate alternatives are identified, the medical record should include evidence of the following: evidence that alternatives were tried and were not successful. b. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted on [DATE] with diagnoses that included rhabdomyolysis (muscle breakdown that can be life-threatening), difficulty in walking, and dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). During a review of Resident 78's Order Summary Report dated 1/5/2024, the order summary report indicated Resident 78 had an active order for bilateral (on both sides) side (bed) rails with length to be at one quarter (1/4- rails at the head of the bed that are less restrictive for movement) use as an enabler (bedrails used to aid movement). During a review of Bed Rails-V 2, dated 1/6/2024, the Bed Rails-V 2 indicated the use of bed rails for Resident 78 was assessed with recommendations for one quarter bedrails bilaterally to be used for mobility and transferring purposes. It also indicated the resident or resident representative was educated and provided informed consent, however the field for the name of the resident or resident representative that was educated and provided informed consent was blank. During a review of Resident 78's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 78 had severely impaired cognition (thinking), required partial or moderate assistance (helper provides less than half the effort and lifts or holds trunk or limbs of resident) for changing positions in bed, and needed substantial or maximal assistance (helper provides more than half the effort and lifts or holds trunk or limbs of resident) for transferring to the toilet. 056466 Page 26 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 2/13/2024 at 9:30 am with Resident 78 in Resident 78's room, the resident was lying in bed with both bedrails at the half position (rails that are horizontal and directly in the middle of the bed; more restrictive for movement). Resident 78 stated he cannot get out of bed with the rails in that position. During a concurrent observation and interview on 2/14/2024 at 9:21 am with Certified Nurse Assistant 2 (CNA 2) in Resident 78's room, Resident 78's bedrails were at the half position. CNA 2 stated the bedrails are up to prevent him from falling and getting out of bed. CNA 2 stated the resident moves a lot and doesn't always listen to directions. During a concurrent observation and interview on 2/14/2024 at 9:37 am with Registered Nurse 2 (RN 2) in Resident 78's room, RN 2 showed surveyors both bedrails were at the half position on Resident 78's bed. RN 2 stated there was no consent to have them at the half position. RN 2 further stated, if the bedrails are at the half position it restricts the resident, the resident could try to get out of bed and get hurt. During a review of Facility Verification of Informed Consent, (undated), the Facility Verification of Informed Consent indicated a prolonged use of a device order for one quarter bilateral side rails for Resident 78 and did not indicate a signature and date on the consent form from Resident 78 or Resident 78's representative. During a review of the facility's policy and procedure (P&P) titled, Proper Use of Bed Rails, dated 12/19/2022, indicated, Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. 056466 Page 27 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure the irregularities of the Medication Regimen Review (MRR) identified by the facility's Pharmacy Consultant was acted upon for one of five sampled residents (Resident 83) in accordance with facility's policy and procedure titled, Consultant Pharmacist Reports. This deficient practice had the potential for harm due to missed opportunity by the physician and the licensed staff to act upon the reported irregularities. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated Resident 83's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated, Resident 83 required total dependence with eating, oral hygiene, toileting, shower, upper or lower body dressing and personal hygiene. During a review of Resident 83's Physician's Order dated 11/1/2023, the order indicated to administer to Resident 83, Insulin Aspart subcutaneously (to inject a medication into the tissue layer between the skin and the muscle) solution Pen-injector 100 unit per milliliter, inject per sliding scale (variable scale for insulin dose based on blood sugar level) before meals and at bedtime for diabetes mellitus. During a review of a facility document titled, Consultant Pharmacist's Medication Regimen Review dated 11/17/2023, completed by the facility's Pharmacy Consultant, the document indicated to add to inject insulin within 5 to 10 minutes before meal to the Insulin Aspart (rapid-acting insulin [medication used to help the body turn food into energy and control blood-sugar/glucose levels] that helps lower mealtime blood-sugar spikes) order. During a concurrent record review and interview with Registered Nurse 1 (RN 1) on 2/15/2025 at 12:51 pm, Resident 83's medical record was reviewed. RN 1 stated Aspart needed to be injected within 5 to 10 minutes before breakfast and dinner. RN 1 stated, there were no other clinical documentation that the recommendation from the Pharmacy Consultant was carried out. During an interview on 2/15/2024 at 1:32 pm, with the facility's Director of Nursing (DON), the DON stated, I do not know why the pharmacy recommendation was missed. The DON stated, Medication Regimen Review (MRR) was a monthly recommendation that staff needed to carry out. During a review of the facility's Policy and Procedure (P&P), titled, Consultant Pharmacist 056466 Page 28 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0756 Level of Harm - Minimal harm or potential for actual harm Reports, dated 06/2021, the P&P indicated recommendations are acted upon and documented by the facility staff and or prescriber and physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. The P&P indicated the director of nursing or designated licensed nurse addressed and documents recommendations that do not require a physician intervention, e.g., monitor blood pressure. Residents Affected - Few 056466 Page 29 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 140 and 241) reviewed for the use of antibiotics (medication to treat infection), received the medication with adequate indication for its use. Residents Affected - Some a. Resident 140 did not meet the criteria to receive Cefazolin (an antibiotic medication) intravenously (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein), which started on 2/6/2024, and Maxipime (Cefepime HCl, an antibiotic medication) intravenously, which started on 2/13/2024 for Resident 140's right forearm cellulitis (skin infection) in accordance with the facility's antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). b. For Resident 241, the medication criteria was not met for the use of fluconazole (medication to treat and prevent fungal infection) as treatment of Methicillin Resistant Staphylococcus Aureus (MRSA - form of bacterial infection that is resistant to numerous antibiotics) of the sputum. These failures had the potential for adverse (harmful) consequences for Residents 140 and 241. Findings: During a review of Resident 140's admission record (face sheet), the admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included cellulitis of the right upper limb, Type II Diabetes Mellitus (high levels of sugar in the blood because of a problem in the way the body regulates and uses sugar), and obesity (abnormal or excessive fat accumulation). During a review of Resident 140's History and Physical (H&P) dated 2/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During an observation and concurrent interview with Resident 140 on 2/13/2024 at 10:24 a.m., Resident 140 was in bed awake, alert, oriented, with ongoing IV antibiotic, Maxipime Injection Solution, running through a Peripherally Inserted Central Catheter line (PICC line, a long flexible thin tube or catheter inserted into a vein in the upper arm for long term IV infusion) on the left arm. Resident 140 stated the treatment was for the cellulitis on her right arm. Resident 140 stated Resident 140 was admitted from the acute hospital and was given antibiotics there for seven days and when she was admitted at the facility, the facility gave her another IV antibiotic for seven days which was completed today (2/13/2024). Resident 140 stated the facility started another antibiotic today because her cellulitis did not get any better and the drainage on her cellulitis did not stop. Resident 140 was observed with a bandage on her right forearm which was wet with clear/watery drainage. During a review of Resident 140's Physician's Order dated 2/6/2024, the order indicated to administer Cefazolin Sodium Injection Solution 1 gm (gram) intravenously every 12 hours for seven days for the resident's right forearm cellulitis. The physician's order indicated Cefazolin was started on 2/6/2024 and was completed on 2/13/2024. The physician's order indicated another antibiotic of Maxipime Injection Solution Reconstituted 2 gm intravenously every 12 hours for 10 days for the resident's right forearm cellulitis. The physician's order for Maxipime indicated it is an active order which started on 2/13/2024. 056466 Page 30 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 140's Infection Screening Evaluation (ISE, facility's screening assessment form to determine presence of infection) dated 2/14/2024, the evaluation indicated Resident 140 had no pain, no new or marked increase symptom, and had redness on the skin. The ISE did not indicate if Resident 140 had an infection, and the infection analysis section of the ISE was not completed. During a review of Resident 140's Antibiotic Time Out Form (a reassessments tool to review a patient's antimicrobial [antibiotics] therapy) for the use of Maxipime, dated 2/24/2024, the form indicated the antibiotic was being given for the resident's cellulitis of the right upper limb. Resident 140's presenting clinical symptom was redness and swelling. Resident 140 was afebrile (no fever) and there was no diagnostic testing that was ordered. The Antibiotic Time Out Form indicated the prescribing provider was notified of Resident 140's current clinical status, and the provider determined to continue with the current antibiotic therapy for 10 days. During an interview with the Infection Prevention Nurse (IPN) on 2/16/2024 at 9:29 a.m., the IPN stated the Infection Surveillance Assessment indicated Resident 140 did not meet the criteria for the use of the antibiotic. The IPN stated, the doctor's response on the Antibiotic Time Out Form, which was done because the resident did not meet criteria for the use of the antibiotic, was to continue giving the antibiotic. The IPN stated Resident 140 did have enough symptoms to meet the criteria for the use of the antibiotics, and the culture and sensitivity test (C&S, a laboratory test done to help diagnose an infection and decide what antibiotic to give) from the acute hospital indicated no growth (no organism grew in the culture from the wound). During a review of the facility's Policy and Procedure (P&P), dated reviewed/revised on 12/19/2022, titled Antibiotic Stewardship Program, the P&P indicated the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with the antibiotic use. The P&P indicated Nursing staff would monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48 to 72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. b. During a review of Resident 241's admission Record, the admission record indicated the facility admitted the resident on 2/8/2024, with diagnoses that included Methicillin Resistant Staphylococcus Aureus (MRSA). During a review of Resident 241's Medication Administration Record (MAR) for 2/1/2024 to 2/29/2024, the MAR indicated an order for Resident 241 for fluconazole (antifungal medication) 200 milligrams (mg- unit of measurement) one tablet by mouth, one time a day for MRSA of the sputum for seven (7) days. During a review of Resident 241's General Acute Hospital's (GACH) microbiology report dated 1/10/2024 to 1/26/2024, the report indicated Resident 241 had MRSA of the nares and tracheal aspirate (secretion from the tubes to the lungs). During a review of Resident 241's GACH medication record, the medication record did not indicate the indication for the use of fluconazole. During an interview on 2/15/2024 at 4:39 pm, the Infection Prevention Nurse (IPN) stated there was a documentation the physician was notified of the medication Resident 241 was taking at GACH and the physician to continue medications. The IPN stated fluconazole was not for MRSA. The IPN stated 056466 Page 31 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0757 there was no communication to the physician to clarify the use of fluconazole for Resident 241. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 056466 Page 32 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure two of two bags of meat in a plastic box were not placed directly on the floor in the kitchen preparation area in accordance with facility's Policy and Procedure (P&P), titled Food Storage. This deficient practice had the potential for food borne illnesses (infections caused by ingesting contaminated food or beverages). Findings: During an initial tour of the kitchen on 2/13/2024 at 8:32 am, together with the facility's Assistant Director of Nutrition Services (ADNS), two bags of meat in a plastic box were placed directly on the floor in the meal preparation area. During a concurrent observation and interview on 2/13/2024 at 8:32 am, the ADNS stated, food and food containers should not be placed directly on the floor. ADNS stated, the floor was dirty and putting food directly on the flow can cause food contamination and sickness if eaten by the residents. The ADNS stated food or food containers needed to be placed on a rack. During a concurrent observation and interview on 2/13/2024 at 8:34 am, with the Director of Nutrition Services (DNS), the DNS stated food or food containers needed to be stored six (6) inches off the floor and should be placed on a rack to prevent food contamination. During a review of the facility's P&P titled, Food Storage, revised on 8/29/2023, the P&P indicated, all foods should be stored away from the walls, off the floor and clear of ceiling sprinkles, sewers/waste disposal pipes and vents. 056466 Page 33 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, facility failed to follow the facility's policy and procedure titled Confidentiality of Personal and Medical Records by ensuring one of one sampled resident (Resident 65) 's identifiable, personal and medical information were not exposed on the computer screen unattended and in view of unauthorized persons to view and access confidential information without the resident's consent or knowledge. This deficient practice resulted in Resident 65's violation of resident's right for privacy. Findings: During a review of Resident 65's admission record, the admission record indicated the facility admitted Resident 65 on 1/4/2024 with diagnoses that included type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar) and hyperlipidemia (a condition of having high cholesterol in the blood). During a review of Resident 65's History and Physical (H&P), dated 1/5/2024, the H&P indicated Resident 65 had fluctuating capacity to understand and make decision. During a review of Resident 65's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/26/2024, the MDS indicated, Resident 65's cognition (process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 65 required total dependence with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During an observation of the facility's nursing station on 2/15/2024 at 11:18 am, one computer screen was observed unattended and logged on at Nursing Station 1, exposing Resident 65's identifiable, personal, and medical information. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 2/15/2024 at 11:24 am, LVN 1 stated it was a violation of Resident 65's right to privacy by exposing the resident's personal and medical information. LVN 1 stated the computer screen should not be left on and unattended exposing resident's information. During an interview on 2/15/2024 at 1:37 pm, with the Director of Nursing (DON), the DON stated, staff should maintain confidentiality of resident's personal records. The DON stated, staff needed to close the computer screen if left unattended because anyone could go inside the nurse's station and be able to get access to Resident 65's information without the resident's consent. During a review of facility's Policy and Procedure (P&P) titled Confidentiality of Personal and Medical Records, revised 12/19/2022, the P&P indicated, safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual's surrogate or representative 056466 Page 34 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0880 Provide and implement an infection prevention and control program. 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 staff wear required Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.) when assisting two of three residents (Resident 33 and Resident 240) with meal. Residents Affected - Some These deficient practices had the potential for the spread of infection. Findings: During a review of Resident 33's admission Record, the admission record indicated the facility admitted the resident on 8/25/2023 with diagnoses that included multiple fracture (broken bone) of ribs. During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/16/2023, the MDS indicated the resident had moderate cognitive (ability to understand) impairment and required supervision with rolling left and right and sit to lying mobility. During a review of Resident 240's admission Record, the admission record indicated the facility admitted the resident on 2/6/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 240's MDS dated [DATE], the MDS indicated the resident had moderate cognitive (ability to understand) impairment and required supervision with eating and moderate assistance with toileting, oral hygiene and shower. During an interview on 2/14/2024 at 9:30 am, the Director of Staff Development (DSD) stated, if the staff (in general) did not have close contact with the residents, isolation gown is not needed when entering the room designated as Novel Respiratory Precautions for exposure to a roommate diagnosed with COVID-19 (a respiratory illness that can spread from person to person). During an observation on 2/15/24 at 12:35 pm, Certified Nursing Assistant 3 (CNA 3) and CNA 4 entered Room A (on Novel Respiratory Precautions). CNA 3 and CNA 4 did not wear an isolation gown upon entering the room. CNA 3 assisted Resident 33 with meal set-up, CNA 3 removed lids from the cups and cut up food into small pieces. CNA 4 assisted Resident 240 with meal set-up, removed lids from cups and fed the resident. During an interview on 2/15/2024 at 3:32 pm, the Infection Prevention Nurse (IPN) stated Room A was designated as Novel Respiratory Precautions room. The IPN stated each time a staff enter Room A, staff needed to wear an isolation gown, gloves, N95 (respiratory protective device designed to achieve a very close facial fit) and face shield. During a review of the local guidelines for preventing and managing COVID-19 in Skilled Nursing Facilities, updated 1/25/2024, the guidelines indicated for close contacts, asymptomatic residents, staff needed to wear full PPE per COVID transmission-based precautions when providing care or entering a room where the resident is (resident room, shower room, rehab gym, etc.). During a review of the facility's COVID-19 outbreak line list, the roommate (Resident 86) of Resident 33 and Resident 240 tested positive for COVID -19 on 2/8/2024. 056466 Page 35 of 36 056466 02/16/2024 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to ensure one of five sampled staff (Licensed Vocational Nurse 3 [LVN 3]) was aware to report an allegation of abuse to the Long-Term Care Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care) as required by State and Federal regulations. This deficient practice had the potential for facility staff not to report an abuse incident to the Long-Term Care Ombudsman, which could lead to possible harm and risk of further abuse of the residents. Findings: During an interview on 2/15/2024 at 12:06 pm, with LVN 3 (Charge Nurse), LVN 3 stated, I don't know what is an Ombudsman when asked about reporting agencies if an abuse allegation occurred. LVN 3 stated the two agencies to report allegation of abuse were the State Agency and the local law enforcement. LVN 3 stated LVN 3 received abuse in-service training last month. During an interview on 2/15/2024 at 12:21 pm, with Director of Staff Development (DSD), DSD stated any allegation of abuse should be reported in a timely manner to the State, local law enforcement and the Long-Term Care Ombudsman. DSD stated abuse reporting to the Long-Term Care Ombudsman was required by the State and the Federal regulations. DSD stated the Long-Term Care Ombudsman was an agency who advocate and help residents in nursing homes for their care, health, and safety. During a review of the facility's Inservice Training Report dated 1/27/2024 and attached Lesson Plan titled Prevention, Recognizing, and Reporting abuse dated 7/16/2018, the training indicated, To call the Long-Term Care Ombudsman as soon as practically possible, after the telephone is made, the SOC341 (Report of Suspected Dependent Adult/Elder Abuse) form is completed and must be sent within 24 hours to the Ombudsman Office and if injury occurs report in 2 hours. During a review of the facility's Policy and Procedure (P&P), titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 12/19/2022, the P&P indicated The Administrator or designee will notify the appropriate agencies immediately, as soon as possible, but no later than 24 hours after discovery of the incident. During a review of the facility's P&P, titled Training Requirements, revised 12/19/2022, the P&P indicated All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program. Training requirements should be met prior to staff and volunteers independently providing services to resident, annually, and as necessary based on the facility assessment. 056466 Page 36 of 36