Health inspection·June 3, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of one sampled resident (Resident 1). Resident 1 was hit by Family Member 1 (FM1- Resident 1's brother) during visitation on 5/21/24. This deficient practice resulted in discoloration of Resident 1's right lower lip and left temporal (side) area of the face. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 2/22/24 and readmitted on [DATE] 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 bipolar disorder (mental disorder with periods of depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities] and periods of elevated mood.) During a review of Resident 1's Progress Notes dated 5/21/24 at 3:20 pm, the Progress Notes indicated Resident was on 1:1 monitoring (providing continuous observation for a period of time) due to agitation and aggressiveness. The Progress Notes indicated a staff (unidentified) left Resident 1 because Resident 1's FM1 came to visit him. The Progress Notes indicated according to the staff, both Resident 1 and FM1 were calm and after 5-10 minutes later, Resident 1 was heard yelling loud saying Nurse, Nurse. Resident 1 was sitting on his wheelchair, pointed at FM1, and stated He (FM1) hit me. During a review of Resident 1's Progress Notes dated 5/21/24 at 4:02 pm, the Progress Notes indicated assessment was done on Resident 1, neurocheck (examination of the brain, nerve, and spinal cord functioning) was started and Resident 1 was given Tylenol (medication for pain) for complaint of 6/10 pain (0= no pain and 10=worst pain based on pain scale) on the left temporal area. During a review of Resident 1's Progress Notes dated 5/21/24 at 10:37 pm, the Progress Notes indicated Resident 1 arrived back to the facility from General Acute Care Hospital 1 (GACH 1) with discoloration on his right lower lip and left temporal area of the face related to an incident prior to his transfer to GACH 1. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/22/24, the MDS indicated Resident 1 had severely impaired cognition (ability to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056466 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)