Health inspection·February 21, 2025

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** Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Informed Consent, for the use of wander guard alarm (a system of wearable bracelets and sensors that helps keep residents safe in healthcare facilities) for one of three sampled residents (Resident 59). Residents Affected - Few This failure violated Resident 59's right and placed Resident 59 at risk for psychological distress related to the discomfort from wearing the alarm and the sound of the alarm. Findings: During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Elopement Risk (ER), dated 12/22/2024, the ER indicated Resident 59 was at risk for elopement. During a review of Resident 59's Minimum Data Sheet (MDS, a resident assessment tool), dated 1/6/2025, the MDS indicated, Resident 59 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 59 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing; and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and personal hygiene. During an observation on 2/18/2025 at 10:47 am in the dining room, Resident 59 was sitting on his wheelchair with wander guard alarm bracelet on his right wrist. During a concurrent interview and record review on 2/20/2025 at 10:51 am with Licensed Vocational Nurse 4 (LVN 4), Resident 59's medical records (chart) and PointClickCare (PCC, a cloud-based software platform) were reviewed. LVN 4 stated there was no documented evidence that consent was obtained before the application of a wander guard. LVN 4 stated consent should be obtained to make sure the resident or his responsible party was informed and purpose on the use of wander guard was explained. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, the use of a wander guard alarm system involved a prolonged use of a device and should be consented before its application. DON stated the risks and benefits of using the device should be explained to prevent causing anxiety and discomfort from wearing the device and its sound. Page 1 of 24 056466 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0552 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Resident Alarms, revised 12/19/2022, the P&P indicated, The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary. Residents Affected - Few During a review of the facility's P&P titled, Informed Consent, revised 12/19/2022, the P&P indicated, When situations arise that involve complex decisions, the facility will verify that informed consent had been obtained prior to any medical intervention or treatment is initiated, including, but not limited to, administration of psychotherapeutic medications, application of a physical restraint or the prolonged use of a device that may lead to the inability to regain use of a normal body function and for transfer and discharge. 056466 Page 2 of 24 056466 02/21/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call light was within reach for one of one sampled resident (Resident 89). Residents Affected - Few This failure had the potential for Resident 89 not to received necessary care and services and put Resident 89 at risk for fall. Findings: During a review of Resident 89's admission Record (AR), the AR indicated Resident 89 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss on interest or pleasure in activities) and unsteadiness on feet (gait instability). During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2025, the MDS indicated, Resident 89 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 89 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and toileting hygiene, shower, upper, lower body dressing and personal hygiene. During a revie w of Resident 89's undated Care Plan (CP), the CP indicated Resident 89 was at risk for falls. The CP interventions included to place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. The CP indicated Resident 89 needed prompt response to all requests for assistance. During a concurrent observation and interview on 2/18/2025 at 10:09 am with Certified Nurse Assistant 1 (CNA 1) inside Resident 89's room, Resident 89 was lying in bed with the call light hanging on the wall. Resident 89 stated she did not know where the call light was. CNA 1 stated Resident 89's call light should be placed next to Resident 89 where the resident could see the call light and able to call staff when Resident 89 needs help. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, call light should be within easy reach of the resident. by the bedside to be utilized when needed and needs could be addressed immediately. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 12/19/2022, the P&P indicated, The purpose of this policy is to assure the facility is adequately equipped with a call lights. The P&P indicated staff will ensure the call light is within reach of residents and secured, as needed. 056466 Page 3 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated, Resident 17 had a moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required substantial/maximal assistance (helper did more than half the effort) with oral and toileting hygiene, shower, and personal hygiene. During a concurrent interview and record review on 2/19/2025 at 12:11 pm with the Social Services Director (SSD), Resident 17's Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life), dated 11/3/2021, and Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement Form, dated 7/4/2024 were reviewed. The SSD stated the POLST indicated Resident 17 had no AD. The SSD stated the ADA Form indicated Resident 17 had not executed an AD. The ADA Form had a written note that Resident 17 wished to have an AD in place. The SSD stated there were no records indicated that Resident 17's family member was followed up on an AD or arrangement was done to formulate an AD. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated AD should be in Resident 17's chart (medical record) upon Resident 17's admission. The DON stated the AD helped staff to determine Resident 17's wishes and preferences regarding care in the facility. During a review of the facility's policy and procedure (P&P) titled, Resident Rights Regarding Treatment and Advance Directives, revised 12/19/2022, the P&P indicated, On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Based on interview and record review, the facility failed to follow the facility's policy on Advance Directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three of three sampled residents (Residents 17, 28 and 31) by failing to: 1. Ensure Residents 28 and 31's Advance Directive Acknowledgement Form (ADA) was filled out. 2. Ensure a copy of Resident 17's AD was in the medical chart. These failures had the potential for Residents 17, 28 and 31's preferences not carried out by the facility staff, affecting the residents quality of life. Findings: 056466 Page 4 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and lower back pain. During a review of Resident 31's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 4/18/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a concurrent interview and record review on 2/18/2025 at 11:43 AM with the Social Services Director (SSD), Resident 31's ADA form dated 4/15/2024 was reviewed. The SSD stated the ADA form was not filled out completely and stated there should be a check mark on the form if Resident 31 did or did not have an AD. The SSD stated the risk of not completing the ADA form was that the facility could provide services that were not in accordance with the resident's AD if the resident had formulated an AD. During an interview on 2/20/2025 at 2:30 PM with the Director of Nursing (DON), the DON stated the ADA forms should be filled out completed to indicate the facility inquired if the resident had an AD. The DON stated, the resident would receive the wrong services and the facility would not know the resident's preferences in receiving care during emergency if the ADA form was not filled out. c). During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was originally admitted into the facility on 9/14/2024 and readmitted into the facility on [DATE] with diagnoses that included depression (a mood disorder that may cause persistent sadness or loss of interest in activities) and chest pain. During a review of Resident 28's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 9/23/2024, the POLST indicated Resident 28 had a legally recognized decision maker. During a review of Resident 28's History and Physical (H&P), dated 9/30/2024, the H&P indicated Resident 28 was awake, alert, and followed commands. During a review of Resident 28's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 2/4/20245, the MDS indicated Resident 28 had severely impaired cognition and used a wheelchair for mobility. During a concurrent interview and record review on 2/18/2025 at 11:45 am with the Social Services Director (SSD), Resident 28's Advanced Directive Acknowledgment (ADA) Form, dated 9/23/2024 was reviewed. The ADA Form did not indicate (by checking one of the following statements) that Resident 28 had or had not executed an advance directive. The SSD stated, the ADA form should have been completed on admission and was not complete, making it invalid. During an interview on 2/20/2025 at 2:30 pm with the Director of Nursing (DON), the DON stated the ADA Form should be entirely filled out to indicate if the resident had an Advance Directive. The DON further stated, this allows them to know the resident's wishes, preferences and prevent the risk of the resident receiving the wrong services. During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding 056466 Page 5 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Treatment and Advance Directives, last revised 12/19/2022, indicated it was the facility's policy to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. The P&P indicated, on admission the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. The P&P indicated, in the event the resident is unable to formulate an advance directive due to cognitive impairment the facility will provide information and education to the resident's representative about the right to refuse medical or surgical treatment and formulate an advance directive. 056466 Page 6 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Level I Pre-admission Screening and Resident Review (PASRR) for one of 21 sampled residents (Resident 5) that were in the facility for more than 30 days. This failure had the potential to place the resident at risk for delayed care and to not receive care and services for a mental or intellectual disability. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility readmitted Resident 5 to the facility on 1/27/25 with diagnoses that included malignant neoplasm of esophagus (cancer of the tube that runs from the throat to the stomach) and bipolar disorder (episodes of mood swings from depressive lows to manic highs). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/25, the MDS indicated Resident 5 was severely cognitively impaired (ability to understand and process thoughts), and was totally dependent in lower body dressing and personal and toileting hygiene. During a record review of Resident 5's clinical record, Resident 5's clinical record indicated on 6/13/23, Resident 5's Pre-admission Screening and Resident Review I (PASARR- a federal requirement to determine need and appropriate setting for services) evaluation result was positive, and Resident 5 required a PASARR II evaluation. During an interview, on 2/21/25, at 12:21 p.m., with Admissions Coordinator (AC), the AC stated the AC completes admission and screens resident for PASARR I. The AC stated the AC usually receives the patient from the hospital so AC requests PASARR I from the hospital and AC gives PASARR I to the Minimum Data Set Assistant (MDS A). The AC stated MDS A is responsible for PASARR II. During an interview and record review of Resident 5's PASARR I, on 2/21/25, at 12:34 p.m., with MDS A, MDS A stated the PASARR I is triggered for residents with psychiatric diagnosis or medication or mentally disabled. The PASARR Department (PD) contacts MDS A for additional information or may interview resident, review medications, and confirm if on 5150 hold (involuntary psychiatric detention) of if on any lockdown. After the PASARR I is reviewed by the PD, the PD will update the facility, and a screen letter and determination letter are entered in the PASARR system. The MDS A stated if the resident discharges and returns, a new PASARR I screening is completed by MDS A to trigger another PASARR II and the resident is treated like a new admission because they may have a different diagnosis or medication. The MDS A stated another PASARR I evaluation should have been completed for Resident 5 upon readmission by Admissions, MDS A, or from the hospital to determine if a PASARR II was still needed. MDS A stated PASARR is used to determine if the resident needs the services, psychiatric evaluation or psychiatric services. MDS A stated there should have been a PASARR I screening completed between 6/13/23 and 1/28/25 for Resident 5 due to Resident 5 was readmitted and in facility for more than 30 days. MDS A stated Resident 5 was readmitted to the facility on [DATE] and 5/6/24 from the hospital and there was no PASARR I completed for Resident 5. During a record review of the facility's Policy and Procedure (P&P), titled, Resident Assessment-Coordination with PASARR Program, dated 2022, the policy and procedure indicated all applicants to 056466 Page 7 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0644 Level of Harm - Minimal harm or potential for actual harm this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Exceptions to the preadmission screening program include those individuals who: a. Are admitted directly from a hospital. Residents Affected - Few b. Are admitted directly from the hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 056466 Page 8 of 24 056466 02/21/2025 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 interview and record review, the facility failed to develop a care plan (CP) for the use of Zoloft (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) for one of one sampled resident (Resident 41). This failure had the potential for inconsistency of care for Resident 41 and risk for unnecessary psychotropic medication use. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder and hypertension (high blood pressure). During a review of Resident 41's History and Physical (H&P) dated 11/2/2023, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Order Summary Report (OSR) dated 10/24/2024, the OSR indicated Resident 41 had an active order for Zoloft 50 milligrams (mg, unit of measurement) once a day for depression, manifested by verbalization of sadness. During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment tool) dated 12/5/2024, the MDS indicated Resident 41's had moderately impaired cognitive abilities (ability to think, learn and process information). During a concurrent interview and record review on 2/20/2025 at 10:59 AM with Registered Nurse Supervisor 2 (RN 2), Resident 41's medical record was reviewed. RN 2 stated there was no CP for the use of Zoloft and stated there should be a CP so that staff can monitor if the medication was working and to guide the staff on consistently implementing specific interventions for Resident 41. During an interview on 2/20/2025 at 2:47 PM with the Director of Nursing (DON), the DON stated there was no CP for Zoloft use for Resident 41. The DON stated there should be a CP so that staff would implement interventions for monitoring the effectiveness of the medication for Resident 41. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans revised 12/19/2022, the P&P indicated the comprehensive CP will include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. The objectives will be utilized to monitor the resident's progress and alternative interventions will be documented as needed. 056466 Page 9 of 24 056466 02/21/2025 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** Based on interview and record review, the facility failed to provide the resident with management for constipation for five days (2/15/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25) for one of one sampled resident (Resident 142). Residents Affected - Few This failure resulted in a delay in receiving necessary care & services to manage Resident 142 constipation and had the potential to result in adverse consequences for Resident 142. Findings: During a review of Resident 142's admission Record (AR), the AR indicated the facility admitted the resident on 7/1/24 and readmitted on [DATE] with diagnoses that included othopedic aftercare following surgical amputation (care provided following a medical procedure that involves removal of a body part) and obesity (excessive accumulation of body fat). During a review of Resident 142's History & Physical (H&P) dated 2/16/25, the H&P indicated Resident 142 had the capacity to make medical decisions. During a review of Resident 142's Minimum Data Set (MDS, a resident assessment tool) dated 2/18/25, the MDS indicated Resident 142 had moderately impaired cognition (ability to understand and process thoughts) and required supervision or touching assistance with upper body dressing, dependent for lower body dressing and toileting hygiene. During an interview on 2/18/25, at 10:54 a.m., with Resident 142, Resident 142 stated Resident 142 had constipation. Resident 142 stated Resident 142 did not have bowel movement (BM) since the previous Wednesday, 2/12/25 while in the hospital. Resident 142 stated Resident 142 was taking Norco but does not want Norco because of the side effects of constipation. During a concurrent interview and record review on 2/20/25 at 10:47 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 142 complained of constipation and LVN 2 administered Milk of Magnesia (MOM) on 2/19/25 at 12:00 p.m. with no bowel movement (BM) result. LVN 2 stated residents were rechecked/reassessed in about an hour after medications are given to determine medication effectiveness. LVN 2 stated LVN 2 did not document effectiveness of MOM on Resident 142's MAR. LVN 2 stated LVN 2 was assigned to Resident 142 on 2/18/25 and 2/19/25. LVN 2 stated LVN 2 saw in the resident's medical record that Resident 142 did not have a BM for three days. LVN 2 stated, usually there was a standing Physician's Order (MDO) that if MOM was ineffective, licensed staff needed to give a suppository or maybe enema but Resident 142 did not have this order. LVN 2 stated, for Resident 142, if the medication was ineffective, the physician should have been notified. Resident 142's MAR and Progress Notes indicated there was no follow up or additional medication given for constipation for Resident 142 on 2/19/25 and LVN 2 did not call the physician to report medication ineffectiveness. LVN 2 stated, constipation would affect Resident 142's health and could result in complications and patient discomfort. During a review of Resident 142's MAR for 2/1/25 -2/28/25, the MAR indicated Resident 142's last BM was on 2/14/25. The MAR indicated MOM was not given on 2/15/25, 2/16/25, 2/17/25, and 2/18/25. During a review of Resident 142's Pain Management Care Plan (CP) undated, the CP indicated for staff to monitor, document, and report adverse reaction to analgesic therapy. 056466 Page 10 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P), titled, Provision of Quality Care, dated 2022, the P&P indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Residents Affected - Few 056466 Page 11 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility's policy on foley catheter (FC, thin flexible tube that is inserted into the bladder to drain urine) care for one of one sampled resident (Resident 50) by failing to ensure the FC port was changed when visibly soiled and ensure a FC securement device was placed as ordered. These failures had the potential to put Resident 50 at risk for infection and injury. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH, medical condition which the prostate grows making it difficult to urinate) and sepsis( life-threatening condition that arises when the body's response to infection injures its own tissues and organs). During a review of Resident 50's History and Physical (H&P) dated 8/11/2024, the H&P indicated Resident 50 did not have the capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (MDS, a standardized assessment tool) dated 12/2/2024, the MDS indicated Resident 50 had severely impaired cognitive abilities (ability to learn, think, and process information). The MDS indicated Resident 50 had an indwelling catheter (FC). During a review of Resident 50's untitled and undated Care Plan (CP), the CP indicated Resident 50 had an indwelling catheter and indicated to apply the catheter stabilization device to ensure the FC was in place and to place a secure device immediately if not on. During a review of Resident 50's Order Summary Report (OSR) dated 12/11/2024, the OSR indicated an order for licensed staff to apply a catheter stabilization device to ensure the FC was in place. During a concurrent observation and interview on 2/18/2025 at 11:16 AM with the Infection Prevention Nurse (IPN), Resident 50s' FC port was observed with brown substance and the FC did not have a securement device. The IPN stated the brown substance looked like feces on the FC port. The IPN stated there was no FC securement device. The IPN stated the visibly soiled FC could put the resident at risk for infection. The IPN stated, without a securement device, the resident could be at risk of injury because the FC could be pulled out by accident. During an interview on 2/19/2025 at 3:13 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated licensed nurses needed to ensure a securement device was on for a FC. LVN 4 stated FC could be pulled out by accident if there was no securement device. LVN 4 stated if the FC becomes soiled, it should be changed immediately because it would put the resident at risk for infection because the tube goes directly to the bladder. During an interview on 2/20/2025 at 2:50 PM with the Director of Nursing, the DON stated if the FC was visibly soiled staff should inform the Registered Nurse Supervisor to change it as soon as possible. The DON stated if the FC was not changed, it could put the resident at risk for infection. The 056466 Page 12 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated if the FC securement device was not on as ordered by the physician, the FC could be pulled by accident and cause injury to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care revised 12/19/2022, the P&P indicated the facility will ensure residents with indwelling catheters receive appropriate catheter care and maintain dignity and privacy when indwelling catheters are in use. 056466 Page 13 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 16) who was receiving tube feeding (TF, liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs), did not have the TF running while the resident was being changed in the supine (lying horizontally on the back with face and torso upward) position. This failure had the potential to result in Resident 16 aspirating (when small particles of food or drops of liquid are breathed into the lungs), which could cause aspiration pneumonia (an infection that occurs in the lungs due to aspiration) and other serious complications. Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was readmitted on [DATE] with diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 16's Care plan (CP), revised on 12/13/2023, indicated Resident 16 required TF related to dysphagia (difficulty swallowing), swallowing problems, cerebral palsy, and intestinal obstruction which required surgery. The CP indicated, Resident 16 was at high risk for multiple complications including nausea, vomiting, and aspiration. The CP indicated, the HOB should be elevated at least 30-45 degrees during and thirty minutes after TF. During a review of Resident 16's History and Physical (H&P), dated 2/20/2024, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 11/20/2024, the MDS indicated Resident 16 was rarely/never understood and while a resident (performed while a resident of the facility and within the last 7 days) Resident 16 had a feeding tube. During a review of Resident 16's Braden Scale for Predicting Pressure Ulcer Risk Evaluation (BS -tool used for assessing residents' risk of development of pressure ulcers-localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), dated 11/20/2024, the BS indicated Resident 16 's mobility (ability to change and control body position) was assessed as completely immobile and the resident did not make even slight changes in body or extremity position without assistance. During a review of Resident 16's Nutritional Assessment (NA), dated 2/10/2025, the NA indicated Resident 16's type of TF was a gastrostomy tube (GT) needed for dysphagia. During a review of Resident 16's Physician Orders Summary Report (PO), dated 2/19/2025, the PO 056466 Page 14 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 16 had an active order for a continuous TF of Fibersource HN (a feeding containing fiber that is nutritionally complete) or the equivalent, to infuse at rate of 45 milliliters per hour (ml/hr.) for 20 hours, to start at 2 pm and continue until the dose is infused, ordered on 2/12/2025. During a concurrent observation and interview on 2/18/2025 at 11:46 am with Licensed Vocational Nurse 1 (LVN 1), Resident 16's TF was infusing while the CNA was changing the resident. The resident was lying in the supine position. LVN 1 stated, she paused the TF pump for 7-10 minutes and it restarted. LVN 1 stated, the TF should be paused when changing the resident to prevent her from choking or aspirating, which could lead to difficulty breathing and further complications to the resident. During an interview on 2/18/2025 at 12:18 pm with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated he changed Resident 16 and asked them to pause it for 10 minutes and the TF started running again, stating sometimes they need more time. CNA 2 stated, he cleaned Resident 16 frequently, approximately every two hours. During an interview on 2/21/2025 at 10:23 am with the Director of Nursing (DON), the DON stated the TF needs to be turned off by the licensed nurse when changing a resident. The DON stated, receiving a TF while a resident was supine could cause aspiration of the TF and could lead to something more serious. During a review of the facility's policy and procedure (P&P) titled, Verifying Placement of Feeding Tube, last revised 12/19/2022, the P&P indicated, the resident's head-of-bed (HOB) should be kept elevated a minimum of 30 degrees at all times during the administration of feedings or medications to prevent aspiration and pneumonia, unless otherwise specified in medical orders or contraindication for other reasons. 056466 Page 15 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0699 Provide care or services that was trauma informed and/or culturally competent. 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 54's admission Record (AR), the AR indicated the facility readmitted Resident 54 into the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD- mental health condition caused by an extremely stressful or terrifying event) and spinal stenosis (spaces inside the bones of the spine get too small). Residents Affected - Some During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/25, the MDS indicated Resident 54 was cognitively intact (ability to understand and process thoughts), and required supervision or touching assistance with upper body dressing and personal hygiene and partial/moderate assistance with lower body dressing and toileting hygiene. During a record review of Resident 54's clinical record and Care Plans, Resident 54 did not have a Care Plan for Resident 54's PTSD diagnosis. During a concurrent interview and record review, on 2/20/25, at 10:37 a.m., of Resident 54's Care Plans, with LVN 2, LVN 2 stated Yes, Resident 54 has a PTSD diagnosis. LVN 2 stated Resident 54's behavior can be non-compliant, such as when Resident 54 does not want tray removed, does not adhere to schedules, and hoarding tendencies. LVN 2 stated PTSD is caused by flashbacks (sudden, involuntary re-experiences of a past event). LVN 2 stated LVN 2 knows Resident 54 is a veteran (served in the armed forces of their country), and maybe has bad memories of things that happened. LVN 2 stated Resident 54 did not have a specific Care Plan for PTSD, but there should be one because of the diagnosis and there should be a specific Plan of Care for PTSD. During an interview, on 2/20/25, at 3:02 p.m. with the Director of Nursing (DON), the DON stated that Resident 54 has a diagnosis of PTSD and is a Vietnam Veteran (served in the United States Armed Forces during the Vietnam War). The DON stated Resident 54 had discussed his experiences with DON. The DON stated per facility policy, Resident 54 requires a Care Plan specific to PTSD. The DON stated it is important to develop an individualized Care Plan for a resident with PTSD to manage symptoms and triggers. During a record review of the facility's Policy & Procedure (P&P), titled, Trauma Informed Care, dated, 2022, the policy indicated it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Based on interview and record review, the facility failed to develop a specific and individualized person-centered care plan to meet the needs of trauma (a psychological and physiological response to an overwhelming, distressing, or life-threatening event or series of events) survivor residents for two of two sampled residents (Residents 17 and 54). These failures had the potential for Residents 17 and 54 not to receive the necessary care, treatment, and services. 056466 Page 16 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0699 Findings: Level of Harm - Minimal harm or potential for actual harm a. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). Residents Affected - Some During a review of Resident 17's Trauma Informed Care Screener (TICS, a tool or process that helps identify if someone had experienced trauma), dated 7/5/2024, the TICS result indicated Resident 17 had positive trauma screen. During a review of Resident 17's History of Present Illness (HPI), dated 8/11/2024, the HPI indicated Resident 17 had history of PTSD. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated, Resident 17 had a moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required substantial/maximal assistance (helper did more than half the effort) with oral and toileting hygiene, shower, and personal hygiene. During a concurrent interview and record review on 2/19/2025 at 3:00 pm with the Registered Nurse Supervisor 1 (RN 1), Resident 17's Care Plans (CP) were reviewed. RN 1 stated, Resident 17 was a veteran and had a diagnosis of PTSD. RN 1 stated there was no care plan developed for Resident 17 to address the diagnosis of PTSD. RN 1 stated care plan should be developed for the staff to know the resident's triggers, and to developed interventions specific for the resident to prevent re-traumatization (experiences where past traumatic memories were triggered). During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, Resident 17 who had diagnosis of PTSD should had a care plan specific for the needs of the resident to identify Resident 17's triggers and address his symptoms to prevent relapse of an old trauma. During a review of the facility's policy and procedure (P&P) titled. Trauma Informed Care, revised 12/19/2022, the P&P indicated, Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivors' need to be respected, informed, connected, and hopeful regarding their own recovery. 056466 Page 17 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 22) had pharmacy recommendations that were signed and dated by the attending physician. This deficient practice had the potential to result in a delay in necessary services, poor continuity of care, and a delay in follow-up on the resident's status. Findings: During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was readmitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 22's History and Physical (H&P), dated 7/12/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 12/31/2024, the MDS indicated Resident 22 had severely impaired cognition and used a wheelchair for mobility. During a concurrent interview and record review on 2/19/2025 at 11:22 am with the Medical Record Director (MRD), Resident 22's Skilled Nursing Pharmacy Recommendations (SNPR) for September 2024 and December 2024 that were flagged in the medical record needing physician signing were reviewed. The September 2024 SNPR indicated, the physician response was undated by Resident 22's attending physician, and the December 2024 SNPR physician response lacked a physician signature and date. The MRD stated, the pharmacy recommendations should be signed and dated by the doctor by the end of the month to indicate if they want to continue or discontinue the pharmacy recommendations. The MRD stated, she believed the physician visited in January 2025 but was unable to find a record of the visit. The MRD further stated, Resident 22's last attending physician note in the medical record was dated 12/28/2024. During an interview on 2/21/2025 at 10:18 am with the Director of Nursing (DON), DON stated during physician visits, the physician should sign the patient's pharmacy recommendations. DON further stated, a signed SNPR was important to indicate physician's evaluation and acknowledgement of their pharmacy recommendations. During a review of the facility's policy and procedure (P&P) titled, Physician Services, last revised 12/19/2022, the policy indicated it was the facility's policy that the medical care of each resident to be under the supervision of a licensed physician. The P&P indicated, physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. 056466 Page 18 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staffing information on the Nurse Staffing Sheet (posted information that contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff) was posted in a prominent place readily accessible to residents and visitors for one of two nursing stations. Residents Affected - Few This failure resulted in nurse staffing information being inaccessible to other residents at the opposite side of the facility. Findings: During observations on 2/18/2025 at 9:10 am, 2/19/2025 at 11:15 am, and 2/20/2025 at 10:30 am, the Nurse Staffing Sheet was only posted at the reception desk near the entrance in the facility across from Nursing Station A. During an interview on 2/20/2025 at 11:30 am with the Director of Staff Development (DSD), the DSD stated staffing was only posted in the reception area and there were no other postings within the facility. The DSD stated, the posting was accessible to visitors and residents who visited the front lobby, but wasn't readily accessible to residents at the other side of the facility by Nursing Station B. During an observation on 2/21/2025 10:01 am, staffing information was only posted at the reception desk near the entrance in the facility. During an interview on 2/21/2025 11:19 am with the DSD, DSD stated the staffing posting was only at the reception desk, and it should also be posted at Nursing Station B to make it more visible and accessible to the other residents. During a review of the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, last revised 9/16/2024, the policy indicated it was the policy of the facility to make nurse staffing information was posted in a prominent place readily accessible to residents and visitors. 056466 Page 19 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the informed consent was signed for the use of Trazodone 50 milligrams (mg, unit of measurement) every night for insomnia (difficulty falling asleep) for one of five sampled residents (Resident 31). This failure had the potential for unnecessary psychotropic medication (drug affecting how the brain works and causes changes in mood, feelings and behavior) for Resident 31. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (persistent pain that lasts for at least three months and significantly impacts a person's life) and low back pain. During a review of Resident 31's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's Order Summary Report (OSR) dated 12/10/2024, the OSR indicated Resident 31 had an active physician's order for Trazodone 50 mg at night for insomnia. During a review of Resident 31's Minimum Data Set (MDS, a standardized assessment tool) dated 1/2/2025, the MDS indicated Resident 31 had intact cognitive abilities (ability to think, learn, and process information). During a concurrent interview and record review on 2/18/2025 at 11:40 AM with Registered Nurse Supervisor 1 (RN 1), Resident 31's Physician Document of Informed Consent (PDIC) form for Trazodone dated 12/10/2024 was reviewed. RN 1 stated Resident 31 did not sign the PDIC form for Trazodone. RN 1 stated if the PDIC was not signed, the risks and benefits of Trazodone were not discussed with the resident and placed the resident at risk for unnecessary medication use. During an interview on 2/20/2025 at 2:33 PM with the Director of Nursing (DON) the DON stated the PDIC form for Trazodone was not signed by Resident 31. The DON stated the PDIC form needed to be signed by the resident to indicate the resident understood the risk and benefits of the medication and if there were any alternatives the resident would want to try first. During a review of the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medication revised on 12/19/2022, the P&P indicated residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. 056466 Page 20 of 24 056466 02/21/2025 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 follow its policy and procedure for infection control and prevention for three of five sampled residents (Residents 10, 59, and 74), by failing to: Residents Affected - Some a. Ensure Staff wore the appropriate Personal Protective Equipment (PPE- minimizes exposure to hazards) while providing care five residents on Enhanced Barrier Precautions (EBP- infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) while providing care to Resident 74. b. Ensure an appropriate signage indicating Resident 59's transmission-based precaution (TBP, set of infection control guidelines used in healthcare settings to prevent the spread of infectious diseases than can be transmitted through contact with an infected person) was posted outside the resident's room. c. Ensure Certified Nursing Assistant 4 (CNA 4) wore the required PPE when changing Resident 10's linen. These deficient practices had the potential to result in cross contamination and the spread of infection. Findings: a. During a review of Resident 74's admission Record (AR), the AR indicated the facility readmitted Resident 74 on 1/26/25 with diagnoses that included COVID 19 (virus), methicillin resistant staphylococcus aureus (MRSA- bacteria resistant to many antibiotics), immunodeficiency (condition that weakens or eliminates the immune system's ability to fight disease and infection). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 1/30/25, the MDS indicated Resident 74 was severely cognitively impaired (ability to understand and process thoughts) and was on isolation or quarantine for active infectious disease. During a review of Resident 74's History & Physical (H&P), dated 2/2/25, the H&P indicated Resident 74 did not have the capacity to make medical decisions. During a concurrent observation and interview, on 2/18/25, at 3:58 p.m., Certified Nurse Assistant (CNA 5) was observed changing Resident 74's diaper. Resident 74 was on Enhanced Barrier Precautions (EBP). CNA 5 was observed wearing gloves and not wearing a gown while changing Resident 74. CNA 5 stated CNA 5 was changing Resident 74 and CNA 5 should be wearing a gown, mask, and gloves when changing Resident 74. CNA 5 stated CNA 5 was not wearing a gown while CNA 5 was changing Resident 74's diaper. CNA 5 stated CNA 5 should wear a gown. CNA 5 stated it was important because it's EBP you don't want to get sick and Personal Protective Equipment (PPE) protects her and the resident. During an interview, 2/19/25, at 3:10 p.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated EBP was used mostly when the resident has a gastrointestinal tube (delivers liquid nutrition directly to the stomach or small intestine) (G-tube- delivers liquid nutrition directly to the stomach or small intestine), multidrug-resistant organism (MDRO- resistant to multiple antibiotics or antifungals), or a wound. LVN 4 stated the resident is vulnerable to anything and we want to protect them. LVN 4 056466 Page 21 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated during cleaning and changing residents, it is very important, and staff need to wear a gown and gloves when a resident is on EBP and wearing only gloves is not the right way. The staff have to gown up and put your gloves on. During an interview, on 2/20/25, at 12:23 p.m., CNA 3 stated EBP is for our protection and the residents' protection. When a resident has a G-tube, catheter (a tube inserted into your bladder to freely drain urine), intravenous line (IV- a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein), it is easier for them to get infection or spread infection to us. CNA 3 stated there are signs near the front of the door and stickers by the door that let us know if a resident is on EBP. CNA 3 stated the appropriate PPE to be worn when providing care to an EBP resident includes gloves, gowns, mask, and a face shield, depending on the kind of condition they have. CNA 3 stated using the proper PPE is important because it provides protection for us, the resident and other residents from any kind of infection or illness. During an interview, on 2/20/25, at 1:54 p.m., with the Infection Preventionist (IP), the IP stated not using the proper PPE affects the resident's safety and presents a risk for infections. The IP stated the PPE to be worn when providing care to EBP residents is gown and gloves. The IP stated If staff is wearing only gloves and no gown while changing a resident on EBP, the staff is not wearing proper PPE. During a record review of the facility's Policy & Procedure (P&P), titled, Enhanced Barrier Precautions, dated 2024, the policy indicated Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include changing briefs or assisting when toileting. b. During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Minimum Data Sheet (MDS, a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 59 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 59 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing; and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and personal hygiene. During a review of Resident 59's Specimen Preliminary Report (SPR), dated 2/3/2025, the SPR indicated Resident 59 had resistance to Extended-spectrum beta lactamase (ESBL, a bacterial infection resistant to many antibiotics making them harder to treat) in the urine. During a review of Resident 59's Order Summary Report (OSR), dated 2/10/2025, the OSR indicated Resident 59 was on contact isolation related to ESBL of the urine. During a concurrent observation and interview on 2/18/2025 at 10:47 am with the Treatment Nurse (TN) outside Resident 59's room. The TN stated Resident 59 was on Enhanced Barrier Precaution (EBP, a set of infection control practices that use gowns and gloves to reduce the spread of 056466 Page 22 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0880 multidrug-resistant organisms [MDROs]) because Resident 59 had a positive ESBL in the urine. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 2/18/2025 at 3:25 pm with the Infection Prevention Nurse (IPN), Resident 59's medical records (chart) and PointClickCare (PCC, a cloud-based software platform) were reviewed. IPN stated, there was no documented evidence that Resident was cleared out of contact isolation (a type of infection control precaution used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their environment) and infection was colonized (when microorganism, like bacteria or fungi, lives on or inside the body without causing a disease). The IPN stated Resident 59 should be maintained on contact isolation until cleared to prevent spread of infection to the other residents. Residents Affected - Some During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, Resident 59 who was on transmission-based precautions should be reassessed and cleared out of infection for the safety of the other residents in the facility and cohorted properly. During a review of the facility's P&P titled, Transmission-Based (Isolation) Precautions, revised 7/18/2023, the P&P indicated, Cohorting residents with the same pathogen. The order for transmission-based precautions/isolation will specify the type of precaution and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside of the resident's room, wing, or facility wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. c. During a review of Resident 10's AR, the AR indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia (paralysis of both arms and legs) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks). During a review of Resident 10's H&P dated 4/30/2024, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report (OSR) dated 6/21/2024, the OSR indicated an active physician's order for EBP related to risk for multidrug resistant organism infection (MDRO, bacteria that is resistant to antibiotics) due to presence of a gastrostomy tube (G-tube, thin flexible tube that is inserted into the stomach). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had problems with short-term and long-term memory and was dependent on staff for rolling left and right. During a review of Resident 10's undated and untitled care plan (CP), the CP indicated Resident 10 was on EBP as of 5/31/2023. The CP indicated for staff to wear gown and mask when changing contaminated linen. During a concurrent observation and interview on 2/18/2025 at 10:43 AM with Certified Nursing Assistant 4 (CNA 4) in Resident 10's room, an EBP sign was posted outside Resident 10's room. CNA 4 was inside Resident 10's room and was changing Resident 10's linen. CNA 4 was only wearing gloves. CNA 4 056466 Page 23 of 24 056466 02/21/2025 Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated CNA 4 was not wearing the full PPE when changing Resident 10's linen and should have worn a gown and gloves. CNA 4 stated wearing the required PPE would prevent the transmission or microorganisms (germs). CNA 4 stated, gown and gloves should have been worn when changing the resident's linens because it was considered a high contact activity. During an interview on 2/20/2025 at 1:52 PM with the Infection Prevention Nurse (IPN), the IPN stated staff needed to wear the required PPE prior to entering an EBP room and when changing the resident's linen. The IPN stated, not wearing PPE would put the resident at risk for infection. During an interview on 2/20/2025 at 2:41 PM with the Director of Nursing (DON), the DON stated staff needed to wear the required PPE for direct and high contact activity in EBP rooms. The DON stated changing linens would be considered a high contact activity. The DON stated not donning the required PPE could spread infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions revised 6/17/2024, the P&P indicated PPE for EBP was necessary when performing high-contact care activities which included changing linens. 056466 Page 24 of 24