Health inspection·June 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Norco tablet 5-325 (hydrocodone-acetaminophen) give one tablet by mouth every six hours as needed for moderate (five to seven out of 10, on a pain scale of 0-10, 0-no pain to 10 severe pain) to severe (eight to 10 out of 10) pain, started on 11/30/2022. During a review of Resident 1 ' s MAR for 5/2023 indicated Norco was administered on 5/14/2023, 5/15/2023, 5/19/2023, 5/20/2023, 5/21/2023, 5/22/2023, 5/28/2023, and 5/31/2023. No documentation of nonpharmacological interventions prior to the administration of Norco was indicated in the MAR for the entire month of 5/2023. During a concurrent interview and record review on 6/13/2023 at 12:18 PM, the MDSN stated, staff were supposed to attempt nonpharmacological interventions for pain management and document the interventions before administering Resident 1 ' s Norco medication. The MDSN stated, on 5/14/2023, 5/15/2023, 5/19/2023, 5/20/2023, 5/21/2023, 5/22/2023, 5/28/2023, and 5/31/2023, Norco was given to Resident 1, however nonpharmacological interventions were not attempted or documented on Resident 1 ' s MAR. The MDSN stated, staff were not following Resident 1 ' s plan of care if nonpharmacological interventions were not attempted and documented. During an interview on 6/13/2023 at 2:20 PM, Resident 1's Responsible Party 1 (RP 1) stated, sometimes he saw staff try other methods of pain relief for Resident 1 but not every time. RP 1 stated, Resident 1 was on a lot of pain medications and using nonpharmacological pain relief interventions made RP 1 feel better that everything was being done to relieve Resident 1's pain. During an interview on 6/13/2023 at 3:17 PM, Licensed Vocational Nurse 1 (LVN 1) stated, if Resident 1 requested Norco, LVN 1 was supposed to attempt a nonpharmacological intervention first and had to document the interventions in the MAR. LVN 1 stated, if she did not do that, then she would not be following the orders or the care plan. LVN 1 stated, the nonpharmacological interventions included distraction, back rub/massage, watching TV, and others. During a concurrent interview and record review, on 6/13/2023 at 4:35 PM, with the Director of Nursing (DON), The DON reviewed Resident 1 ' s MAR. The DON confirmed that on 5/14/2023, 5/15/2023, 5/19/2023, 5/20/2023, 5/21/2023, 5/22/2023, 5/28/2023, and 5/31/2023, Resident 1 ' s Norco order was administered, however there was no documentation on the MAR that nonpharmacological interventions were attempted. The DON stated, staff should have followed the care plan and attempted the nonpharmacological intervention prior to administering Norco. The DON stated, staff were not providing Resident 1 with all pain relief options and could potentially put the resident at risk for over medication by not attempting a nonpharmacological intervention first. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 11/2022, a comprehensive, person-centered care plan that included measurable objectives and timetables to meet resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P indicated identified problem areas and their causes and developing interventions that targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. It also indicated care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making. The P&P also indicated the comprehensive, person-centered care plan will describe services that are to furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555055 If continuation sheet Page 2 of 4 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 555055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldwin Gardens Nursing Center 10786 Live Oak Avenue Temple City, CA 91780 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 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 staff failed to follow standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) in accordance with the facility's policy and procedures (P&P) and Centers for Disease Control and Prevention (CDC, a federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) guidelines: Residents Affected - Some a. Certified Nurse Assistant 1 (CNA 1) did not perform hand hygiene (procedures that included the use of alcohol-based hand rubs (ABHR containing 60% to 90% alcohol) and hand washing (with soap and water) before entering and after providing care sample Resident 5 and 6. b. CNA 2 failed to perform hand hygiene or hand washing prior to donning (putting on) personal protective equipment (PPE refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) prior to entering sample Resident 4's room. This deficient practice had the potential to transmit infection agent from a contaminated area, and spread infectious agents from resident to resident, that could result in a wide-spread infection in the facility. Findings: a. During a review of Resident 5's admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and again on 2023, with diagnoses that included neuromuscular bladder dysfunction (a lack of bladder control due to a brain, spinal cord, or nerve problem) and dementia (a progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). During a review of Resident 6's admission Record indicated Resident 6 was initially admitted to the facility on [DATE], with diagnoses that included dementia and generalized muscle weakness (weakness of muscles caused by lack of exercise, ageing, injury, or disease). During a concurrent observation and interview, on 6/16/2023 at 3:30 PM, in the room of Residents 5 and 6, CNA 1 was observed assisting Resident 5. CNA 1 touched Resident 5 ' s arm and shoulder while talking to him and then touched his bedding and privacy curtain. CNA 1 did not perform hand hygiene after. Resident 6 then called for assistance. The CNA 1 then proceeded to open Resident 6 ' s bedside drawer and pull out a soda. CNA 1 did not perform hand hygiene before assisting Resident 6. CNA 1 opened a straw and the soda for Resident 6. CNA 1 stated, he was supposed to perform hand hygiene in between residents and before and after touching residents and their belongings. CNA 1 stated, hand hygiene was important so he does not spread microorganisms and if he did not perform hand hygiene then he could spread infection from resident to resident. CNA 1 stated, he could potentially be exposing the residents to Coronavirus-19 (COVID-19- an infection respiratory disease caused by the SARS-CoV-2 virus) if he did not perform hand hygiene. b. During a review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and again on 1/28/2023, with diagnoses that included dementia and sepsis (the body ' s overwhelming response to infection that is a life-threatening emergency). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555055 If continuation sheet Page 3 of 4 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 555055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldwin Gardens Nursing Center 10786 Live Oak Avenue Temple City, CA 91780 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview, on 6/16/2023 at 3:41 PM, in the common hallway, CNA 2 was observed donning PPE before going into Resident 4's room. CNA 2 did not perform hand hygiene before donning PPE. There were signs outside of Resident 4 ' s room door indicating to perform hand hygiene before donning PPE. CNA 2 stated, he was supposed to perform hand hygiene before donning PPE to protect the residents from germs. CNA 2 stated, he was going to Resident 4 ' s room, who was positive for COVID-19. CNA 2 stated, that COVID-19 was circulating in the facility and if he did not perform hand hygiene, he could be spreading it. During an interview on 6/13/2023 at 4:29 PM, the Infection Prevention Nurse (IPN nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated hand hygiene was supposed to be performed at the beginning of the shift, before and after resident care, before and after coming in and out of residents ' rooms, before and after touching residents and their belongings, in between residents and before they don PPE. The IPN stated, hand hygiene prevented infection and contamination of others and themselves. The IPN stated, staff could cause cross-contamination and spread of infection throughout the facility and added she had been doing weekly in-services on hand hygiene since the facility ' s COVID-19 rates went up in 5/2023. During a review of the facility ' s policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 11/2022, indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The P&P indicated to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water for the following situations: before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, before and after entering isolation precautions setting and before and after assisting a resident with meals. During a review of the CDC, Hand Hygiene Guidance for Healthcare Settings, dated 1/30/2023, indicated healthcare personnel should use ABHR or wash with soap and water immediately before touching a resident, after touching a resident or the resident's immediate environment and immediately after glove removal. https://www.cdc.gov/handhygiene/providers/guideline.html FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555055 If continuation sheet Page 4 of 4