Health inspection·August 4, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behavior exhibited by Resident 1 during Resident 1's previous stay. The MD/A stated the facility did not receive, request, and review Resident 1's updated information and referral from GACH 1, following the inquiry from GACH 1, when GACH 1 SS 1 contacted the facility on 7/31/2025. The MD/A stated usually the DON and the Infection Preventionist (IP) review the referral from GACH (in general) to determine if the facility can provide appropriate care to the resident and provide approval for admissions to the facility. The MD/A stated MD/A did not inform the DON about GACH 1's inquiry about transferring Resident 1 back to the facility. During a concurrent interview and record review on 8/1/2025 at 3:52 p.m. with Registered Nurse (RN) 1, Resident 1's Progress Notes (PN), dated 7/22/2025, were reviewed. RN 1 stated that on 7/22/2025, around 2 p.m., Resident 1 was newly admitted to the facility from GACH 2. RN 1 stated that Resident 1 was transferred to GACH 1 on 7/22/2025 around 9 p.m. for further evaluation of Resident 1's behaviors and increased confusion. Resident 1's PN, dated 7/22/2025 and timed at 9:17 pm, indicated Resident 1 went in other resident's rooms, removed items from other resident's closet, wandered aimlessly up and down the hallway, and touched medication carts and other items. The PN also indicated staff were able to redirect Resident 1 and assisted Resident 1 back into Resident 1's room or wheelchair but Resident 1 continued to repeat the same behaviors. The PN indicated Resident 1 was transferred to GACH 1 for further evaluation due to Resident 1's behaviors and increased confusion. During an interview with the DON on 8/4/2025 at 4:15 p.m., the DON stated the DON did not know GACH 1 called the facility on 7/31/2025 regarding transferring Resident 1 back to the facility. The DON stated the facility should have requested updated information from GACH 1 regarding Resident 1's condition on 7/31/2025 so that the DON and the IP could review Resident 1's records to determine if the facility could provide care to meet Resident 1's needs. The DON stated Resident 1 would be accepted for readmission to the facility with dementia and on psychoactive medications (affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) if Resident 1 did not have any behavioral issues (persistent and disruptive behaviors that negatively impact an individual's ability to function effectively in daily life and social interactions). The DON stated the facility could readmit Resident 1 if the facility could meet Resident 1's needs. During a concurrent interview and record review on 8/1/2025 at 4:23 p.m. with the DON, Resident 1's Order Summary Report (OSR), dated 7/22/2025, were reviewed. The DON stated there was an order to admit Resident 1 on 7/22/2025 and an order to transfer Resident 1 to GACH 1 for increased confusion on 7/22/2025. The DON confirmed Resident 1 was admitted to the facility and transferred to GACH 1 on 7/22/2025. The DON stated that the DON had not received an inquiry from GACH 1 for transferring Resident back to the facility after 7/22/2025. During a concurrent interview and record review on 8/1/2025 at 4:25 p.m. with the admission Coordinator (AC), the Daily Census, dated 7/31/2025, was reviewed. The AC stated that bed was available for admitting Resident 1 on 7/31/2025. During a review of the facility's Census List dated 7/30/2025, 7/31/2025, 8/2/2025, and 8/3/2025, the Census List indicated that:On 7/30/2025, room [ROOM NUMBER]A bed, room [ROOM NUMBER]B bed and room [ROOM NUMBER]B bed were empty and available.On 7/31/2025, room [ROOM NUMBER]B bed and room [ROOM NUMBER]A bed were empty and available.On 8/2/2025, room [ROOM NUMBER]D bed and room [ROOM NUMBER]A bed were empty and available.On 8/3/2025, room [ROOM NUMBER]D bed was empty and available.During a review of the facility's policy and procedure (P&P) titled, readmission to Facility, dated 12/19/2022, the P&P indicated, Residents who seek to return to the facility after the expiration of the bed-hold period or when state law does not provide for bed-holds, are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident still requires the services provided by the facility and is eligible for Medicare skilled nursing facility or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 2 of 3 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 08/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Medicaid nursing facility services.The facility will not evaluate the resident based on their condition when originally transferred to the hospital. If the facility determines it will not be permitting the resident to return, the medical record should show evidence that the facility made efforts to ascertain an accurate status of the resident's condition.to ensure the resident's condition and needs are within the nursing home's scope of care, based on its facility assessment, prior to hospital discharge. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056466 If continuation sheet Page 3 of 3