Health inspection·February 11, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) and/or code status (describes the type of resuscitation procedures one would like the health care team to conduct if one's heart stopped breathing) were in the resident's medical record for one of one sampled resident (Resident 95). This failure had the potential to result in the delay of treatment to Resident 95 and provide care against the resident's will in the event of a medical emergency. Findings: During a review of Resident 95's admission Record, the admission record indicated Resident 95 was admitted on [DATE], with diagnoses that included acute respiratory failure (lungs cannot adequately provide oxygen to the body, leading to low blood oxygen level) and immunodeficiency (decreased ability of the body to fight infections and other diseases). During a review of Resident 95's medical record on 2/10/2024 at 9:03 am, there was no POLST in Resident 95's medical record and no code status documented in Resident 95's electronic health record (EHR). During a concurrent interview, Medical Record Director (MRD) stated Resident 95's POLST was not in Resident 95's medical record and Resident 95's code status was not documented in Resident 95's EHR. MRD stated Resident 95's POLST form or code status needed to be documented in Resident 95's medical record and code status documented electronically in EHR, so that nursing staff were aware of Resident 95's treatment choices in an event of a medical emergency. MRD stated without POLST and/or code status in the resident's medical record, staff had the potential to treat Resident 95 against the resident's will and a violation of resident's right. During an interview on 2/20/2024 at 9:09 am with the Director of Nursing (DON), the DON stated POLST should be kept in the resident's medical record or code status should be documented in resident's EHR for nurses to know the residents' treatment choices during a medical emergency. The DON stated, without the information in the resident's medical record, nurses could treat residents against their will and could affect the residents' quality of life. During a review of the facility's Policy and Procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives, revised 12/19/2022, the P&P indicated, Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 2 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 one of one sampled resident (Resident 7) was free from physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body). Resident 7's bed was against the wall on one side. Residents Affected - Few This failure had the potential to result in accidents or decline in Resident 7's quality of life. Findings: During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted on [DATE], with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way your body metabolizes sugar), history of falling and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). During a review of Resident 7's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 12/16/2023, the MDS indicated Resident 7 had clear speech, made self-understood and understands others. The MDS indicated Resident 7 required substantial assistance (helper does more than half the effort) to roll left and right and transfer from bed-to-chair transfer. During an observation on 2/9/2024 at 5:36 pm, Resident 7 was sitting up in bed talking to a roommate. Resident 7's right side of bed was placed against the wall. During an observation and concurrent interview on 2/10/2024 at 4:30 pm, Resident 7 was sleeping in bed, bed at lowest position with floor mats at both sides. Licensed Vocational Nurse 1 (LVN 1) stated staff recently moved Resident 7's bed away from the wall. LVN 1 stated, placing one side of the bed against the wall was considered a physical restraint because it restricted the freedom and movement for Resident 7 to get out of bed from the right side of the bed. LVN 1 stated Resident 7 could become agitated and depressed if the resident was not able to access the right side of the bed. The Director of Nursing (DON) stated the facility should not place resident's bed against the wall and it was considered a restraint because it prevented Resident 7 to get out from one side of the bed. The DON stated this could affect the resident's mental and emotional well-being. During a review of the facility's Policy and Procedure (P&P) titled, Restraint Free Environment, revised 12/19/2022, the P&P indicated, Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 3 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 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. Based on interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 4) as indicated in the facility's Policy and Procedure, titled Comprehensive Care Plans. This deficient practice had the potential for Resident 4 not to receive the necessary care, treatment, and services. Findings: During a review of Resident 4's admission record, the admission record indicated, the facility admitted Resident 4 on 5/27/2023 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 chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 4's History and Physical (H&P), dated 12/19/2023, the H&P indicated Resident 4 did not have the capacity to understand and make decision. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/11/2024, the MDS indicated, Resident 4's cognition (ability to understand) for daily decision making was severely impaired. The MDS indicated Resident 4 required total dependence with oral hygiene, toileting, shower, lower body dressing and personal hygiene. During a review of Resident 4's Physician's Order, dated 2/8/2024, the order indicated to restart intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) every 96 hours and as needed for nutritional hydration when IV multivitamins is available. During a concurrent interview and record review on 2/9/2024 at 7:16 pm, with Registered Nurse 1 (RN 1), Resident 4's medical record was reviewed. RN 1 stated a care plan was not developed and implemented to address interventions for Resident 4 with peripheral IV line. RN 1 stated there was no other clinical documentation that care plan was developed for Resident 4 to address peripheral IV line. RN 1 stated, a care plan needed to be developed and interventions should have been implemented to address Resident 4's peripheral IV line. During an interview and concurrent record review on 2/10/2024 at 4:17 pm, with the Director of Nursing (DON), the DON stated a care plan was needed to be developed for the staff to determine the plan of care and necessary interventions needed to provide to Resident 4's peripheral IV line. During a record review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Pans, revised 12/19/2022, the P&P indicated other factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be addressed in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 4 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 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** b. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted to the facility on [DATE], with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way the body metabolizes sugar), history of falling and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had clear speech, made self-understood and understands others. The MDS indicated Resident 7 required substantial assistance (helper does more than half the effort) to roll from left and right and transfer from bed-to-chair. During an observation and concurrent interview on 2/9/2024 at 5:36 pm, Resident 7 was sitting in bed. There was a floor mattress at the left side of Resident 7's bed. The floor mattress was more than a feet away from Resident 7's bed. Licensed Vocational Nurse 2 (LVN 2) stated Resident 7 was at risk for falls and staff used the floor mattress to prevent injury if Resident 7 fell out of bed. LVN 2 stated the floor mattress needed to be placed close to Resident 7's bedside so that in an event of a fall, the resident would fall on the mattress instead of floor. During an interview on 2/11/2024 at 9:29 am, LVN 1 stated Resident 7 had a history of falls and at risk for falls. LVN 1 stated Resident 7's floor mattress should be placed close to the resident's bedside to prevent Resident 7 from injury if Resident 7 would fall from the bed. During a review of the facility's Policy and Procedure (P&P) titled, Fall Prevention Program, revised 12/19/2022, the P&P indicated Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for three of three sampled residents (Residents 7, 9 and 29) by failing to: a. Ensure the bed was at the lowest position for Residents 9 and 29 who were assessed as high risk for falls. b. Ensure the floor mattress (device used to reduce fall related trauma if a patient gets up from bed, loses balance, and falls to the floor) was placed close and not away from bed for Resident 7 who was assessed as high risk for fall. These deficient practices had the potential for accidents and severe injury secondary to falls for Residents 7, 9 and 29. Findings: a. During a review of Resident 9's admission Record, the admission record indicated the facility admitted the resident on 12/17/2021, with diagnoses that included seizures (abnormal movements or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 5 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0689 Level of Harm - Minimal harm or potential for actual harm behavior due to unusual electrical activity in the brain,) and contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.) During a review of Resident 9's care plan for risk for fall dated 12/19/2021, the care plan indicated to keep the resident's bed low and to follow the facility's fall protocol. Residents Affected - Some During a review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/7/2023, the MDS indicated the resident had severe cognitive (ability to understand) impairment. The MDS indicated Resident 9 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort,) with rolling from left and right, sit to lying and transfers.) During a review of Resident 9's Fall Risk assessment dated [DATE], the fall risk assessment indicated the resident was at risk for fall due to intermittent confusion, required assistance with elimination, poor vision status, and required the use of assistive devices. During a concurrent observation and interview on 2/11/2024 at 2:40 pm, Resident 9's bed was not at its lowest position; the top of the mattress was around mid-thigh level. The Director of Staff Development (DSD) moved and changed the bed to its lowest position (when the bed stops moving down while pressing the bed control) and the top of the mattress was now at the level above the knee. The DSD stated Resident 9's bed needed to be in the lowest position so the risk for injury will be lower in case of a fall. During a review of Resident 29's admission Record, the admission record indicated the facility admitted the resident on 7/2/2019 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 generalized body weakness. During a review of Resident 29's care plan for risk for fall dated 8/22/2021, the care plan indicated the resident needs a safe environment that included to keep the bed in low position at night and to follow the facility's fall protocol. During a review of Resident 29's Fall Risk assessment dated [DATE], the fall risk assessment indicated the resident was assessed as at risk for fall due to being disoriented at all times, had a history of 1-2 falls in the past 3 months, required assistance with elimination, had poor vision and the had decreased muscular coordination, with jerking or being unstable when making turns. During a review of Resident 29's SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 12/31/2023, the SBAR indicated Resident 29 had a fall on 12/31/2023. The SBAR indicated the resident was found on the floor with his head, shoulder, and hip on the left side of the bed. During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 was severely impaired with making decisions regarding tasks of daily life. The MDS indicated Resident 29 was dependent with all activities of daily living. During a concurrent observation and interview on 2/11/2024 at 2:50 pm, Resident 29's bed was not at its lowest position; the top of the mattress was at upper thigh level. The DSD moved and changed the bed to its lowest position and the top of the mattress was now at the level above the knee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 6 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0689 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) dated 12/19/2022, titled Fall Prevention Program, the P&P indicated At Risk Protocols included to provide additional interventions as directed by the resident's assessment, including but not limited to; assistive devices, increased frequency of rounds, sitter, if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education and therapy services referral. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 7 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 label the nasal cannula (NC) tubing (an oxygen delivery device) for one of two sampled residents (Resident 95). Residents Affected - Few This failure had the potential to result in infection for Resident 95. Findings: During a review of Resident 95's admission Record, the admission record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and immunodeficiency (decreased ability of the body to fight infections). During a review of Resident 95's Order Summary Report for 2/2024, the order report indicated Resident 95 had an order for oxygen via NC at 4 liters per minute every shift. During an observation on 2/9/2024 at 6:06 pm, Resident 95 was in bed with eyes closed. Resident 95 had ongoing oxygen via NC at 4 liters per minute. During a concurrent interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 95's NC was not labeled with date when NC was applied to the resident. LVN 1 stated, Resident 95's NC needed to be changed weekly for infection control purpose. During an interview on 2/11/2024 at 2:55 pm, Infection Preventionist Nurse (IPN) stated the facility change NC tubing every Sunday night shift or as needed when NC become dirty. The IPN stated staff needed to label NC with date so staff would know when the NC was changed. The IPN stated this measure was for infection control purposes. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Concentrator, revised 12/19/2022, the P&P indicated Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 8 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0698 Provide safe, appropriate dialysis care/services 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 interview and record review, the facility failed to document fluid intake every shift for one of one sampled resident on fluid restriction from 1/20/2024 to 2/10/2024 (Resident 19). Residents Affected - Some This failure had the potential to result in adverse consequences for Resident 19. Findings: During a review of Resident 19's admission Record, the admission record indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream]), dependence on renal dialysis and type 2 diabetes mellitus (a chronic condition that affects the way the body metabolizes sugar). During a review of Resident 19's Order Summary Report dated 1/20/2024, the order summary report indicated Resident 19 was placed on fluid restriction of 1200 milliliters (ml) every 24 hours. During a review of Resident 19's Minimum Data Set (MDS- a resident assessment and care screening tool) dated 1/25/2024, the MDS indicated Resident 19 had clear speech, able to understand others and able to make self-understood. The MDS indicated Resident 19 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating and partial/moderate assistance (helper does less than half the effort) for personal hygiene. During an interview and concurrent record review of Resident 19's clinical record on 2/10/2024 at 4:20 pm, Licensed Vocational Nurse 1 (LVN 1) stated there was no monitoring for fluid intake for Resident 19 on fluid restriction. LVN 1 stated Resident 19's physician's order for fluid restriction started on 1/20/2024. LVN 1 stated Resident 19's fluid intake was not documented in Resident 19's medical record from 1/20/2024 up to the present date (2/10/2024). LVN 1 stated the facility had fluid intake and output form to document intake and output amount for residents on fluid restriction. LVN 1 stated staff needed to monitor the amount of Resident 19's fluid intake to prevent Resident 19 from fluid overload or dehydration. During an interview on 2/11/2024 at 10 am with the Director of Nursing (DON), the DON stated any resident on fluid restriction needed to be monitored for fluid intake to prevent possible fluid overload or dehydration. The DON stated, fluid overload may cause shortness of breath, respiratory failure, and hospitalization. The DON stated fluid intake amount needed to be documented to ensure Resident 19 did not take fluid more than ordered by the physician. During a review of the facility's Policy and Procedure (P&P) titled, Fluid Restriction, revised 12/19/2022, the P&P indicated It is the policy of this facility to ensure that fluid restriction will be followed in accordance to physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 9 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview, and record review, the facility failed to conduct annual competency for one of four sampled facility staff (Certified Nursing Assistant 2 (CNA 2). A CNA is a healthcare professional who provides basic care to patients under the supervision of a licensed nurse. This deficient practice had the potential for staff to not have the necessary skills to provide care to the residents. Findings: During a review of employee's files on 2/11/2024 from 11:32 am to 12:10 pm, the employee files indicated the facility did not conduct an annual competency assessment for CNA 2 for the Certified Nursing Assistant Skills. During a concurrent interview, the Director of Staff Development (DSD) stated CNA 2 worked both as CNA and Restorative Nursing Assistant (RNA - is a type of nursing assistant trained to help nurses in restoring mobility of residents). The DSD stated there was no competency assessment for the CNA skills for CNA 2. The DSD stated competency skills assessment needed to be completed annually to ensure the staff have the skills to take care of the residents at the facility. During a review of CNA 2's employee file, the file indicated CNA 2 was hired on 11/21/1990. During a review of the facility's Policy and Procedure (P&P), titled Evaluation Process, dated 12/19/2022, the P&P indicated the facility will review the work performance of employees with a formal written evaluation annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 10 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon the pharmacist's monthly Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication)'s recommendations for one of five sampled residents (Resident 7). This failure had the potential to result in ineffective medication management that could result in adverse consequences (undesirable or non-therapeutic effect of the medication) to Resident 7. Findings: During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way the body metabolizes sugar), history of falling and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). During a review of Resident 7's Minimum Data Set (MDS - a resident assessment and care screening tool) dated 12/16/2023, the MDS indicated Resident 7 had clear speech, made self-understood and understands others. The MDS indicated Resident 7 required substantial assistance (helper does more than half the effort) to roll from left and right and transfer from bed-to-chair. During a review of the Pharmacist's Note to Attending Physician/Prescriber for Resident 7, agreed and signed by the physician on 11/2/2023, the pharmacist recommended, Resident 7 was on Calcium Carbonate-Vitamin D (a dietary supplement used for people who have bone problems or low calcium and vitamin D levels) and consider drawing an Albumin (a protein made by liver)/Vitamin D (a fat-soluble vitamin that help the body absorb and retain calcium for building bone) serum (blood) level, and evaluate Resident 7 for the need for further calcium or vitamin D supplementation. During an interview with the Medical Record Director (MRD) on 2/10/2024 at 3:41 pm, MRD stated there was no documentation in Resident 7's clinical record indicated the facility acted upon the pharmacist's recommendation for Resident 7 to order a blood examination to check Resident 7's Albumin and Vitamin D levels. MRD stated staff needed to carry out the pharmacist's recommendation for Resident 7 since Resident 7's physician agreed the pharmacist's MRR recommendation. During an interview with the Director of Nursing (DON) on 2/11/2024 at 10:08 am, the DON stated the pharmacist's MRR recommendation for Albumin and Vitamin D serum level needed to be carried out for Resident 7. The DON stated it was important to determine the Albumin and Vitamin D serum blood levels of Resident 7 so that the physician could adjust the medication dosage based on the laboratory results. The DON stated, Resident 7's pharmacist's MRR recommendation needed to be attended since the physician signed and agreed the recommendation. During a review of the facility's Policy and Procedure (P&P) titled, Medication Regimen Review, revised 12/19/2022, the P&P indicated The pharmacist shall communicate any irregularities to the facility in the following way: verbal or written communication to the attending physician, the facility's Medical Director, and the DON. Facility staff shall complete MRR by pharmacy within 10 days upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 11 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0756 receipt. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 12 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 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 follow its Policy and Procedure (P&P) on Food Storage by failing to clearly label with open date, one opened mayonnaise container jar in one of one kitchen refrigerator and one opened bag with two pieces of chicken patties inside, in one of one kitchen freezer. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents. Findings: During an observation of the facility's kitchen and a concurrent interview with the Dietary Supervisor (DS) on 2/9/2024 at 5:54 pm, there was one opened mayonnaise jar without open date label in the facility's kitchen refrigerator. There was also one opened bag with two pieces of chicken patties inside, in the kitchen freezer that was not labeled with open date. The DS stated, the kitchen staff needed to label the bag with the date it was opened. The DS stated labeling with an open date was to identify the food's expiry date to ensure expired foods were not served to the residents. The DS stated serving expired food to the residents would result in food borne illnesses. During a review of the facility's P&P titled, Food Storage revised 12/20/2019, the P&P indicated All food stored should be dated when it was placed in the storeroom, refrigerator, or freezer. A grease pen should be used in the freezer. Food in all refrigerators must have Use-By dates. Improper storage of food is the main reason for foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 13 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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's identifiable, personal, and medical information were not exposed on the computer screen unattended and in view of unauthorized persons to view and access without the resident's consent or knowledge (Resident 4). This deficient practice resulted in violation of Resident 4's right to privacy. Findings: During a review of Resident 4's admission record, the admission record indicated, the facility admitted Resident 4 on 5/27/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) 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 4's History and Physical (H&P), dated 12/19/2023, the H&P indicated, Resident 4 did not have the capacity to understand and make decision. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/11/2024, the MDS indicated, Resident 4's cognition (ability to understand) for daily decision making was severely impaired. The MDS indicated Resident 4 required total dependence with oral hygiene, toileting, shower, lower body dressing and personal hygiene. During an observation of the facility's nursing station on 2/10/2024 at 10:23 am, one computer screen was unattended and logged on, exposing Resident 4's identifiable, personal, and medical information. During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 2/10/2024 at 10:30 am, RN 1 stated the computer screen need not be left on and unattended, exposing the resident's information. RN 1 stated, it was a HIPPA violation by exposing Resident 1's personal and medical information. RN 1 stated anybody could come and access Resident 4's file and records if the computer was left unattended. During an interview on 2/10/2024 at 4:15 pm, with the Director of Nursing (DON), the DON stated, staff needed to maintain confidentiality of resident's personal records because people could go in and out of the nurse's station and could have access to resident'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 the facility would safeguard the content of information including written documentation, video, audio or other computer stored information from unauthorized disclosure without the consent of the individual or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 14 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 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 that oxygen simple mask (a basic disposable mask, made of clear plastic, to provide oxygen therapy) was kept in the storage bag when not in use for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Oxygen Concentrator. Residents Affected - Few This deficient practice had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified asthma (chronic lung disease that inflames and narrows the airways) with exacerbation (worsening) and dependence on supplemental oxygen. During a review of Resident 1's History and Physical (H&P), dated 11/3/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (standardized assessment and care planning tool) dated 12/23/2023, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 1 required supervision in toileting, shower, lower body dressing and putting on footwear. During a review of Resident 1's Physician's Order dated 1/29/2024, the order indicated for licensed staff to provide oxygen to Resident 1 via simple mask at two (2) liters per minute (L/min) to maintain resident's oxygen saturation (amount of oxygen carried in blood) greater or equal to 92 percent (%), as needed. During an observation on 2/9/2024 at 5:37 pm, Resident 1's unused oxygen simple mask was placed on top of the resident's bed. During an observation on 2/9/2024 at 5:38 pm, with Infection Prevention Nurse (IPN) in Resident 1's room, Resident 1's oxygen simple mask was placed on top of Resident 1's bed. The IPN stated Resident 1's oxygen simple mask needed to be placed inside the storage bag if not in use, to prevent infection. During an interview on 2/10/2024 at 4:18 pm, with the facility's Director of Nurses (DON), the DON stated unused oxygen mask should be placed in a storage bag if not in use to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a review of the facility's policy and procedure (P&P) titled, Oxygen Concentrator, revised 12/19/2022, the P&P indicated, to keep oxygen tubing or mask in plastic bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 15 of 16 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 555107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Care Center 3541 Puente Avenue 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide resident rooms that measured at least 80 square feet per resident for 12 of 13 multiple resident bedrooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14, did not meet the minimum square footage of 80 square feet per resident. This deficient practice had the potential to result in insufficient space to deliver care and services to the residents, affecting the quality of life of the residents. Findings: During an initial tour of the facility on 2/9/2024 from 5:30 pm to 8:00 pm, 12 of 13 resident rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14) did not meet the minimum requirement of 80 square feet of useable living space per resident in a multiple resident bedroom. The following were observed: For Rooms 1 - 4, four beds were occupied with four residents. For room [ROOM NUMBER], four beds were occupied with four residents. For room [ROOM NUMBER], one of four beds was occupied with one resident. For Rooms 8 -12, four beds were occupied with four residents. For room [ROOM NUMBER], two of four beds were occupied with two residents. The above rooms had sufficient space for the residents and staff to move in and out of the room during delivery of care and there was enough space to store the resident's personal items. The residents in these rooms were able to move their wheelchairs while inside the room. There was enough space for the beds, dresser, closets, and other medical equipment. During an interview on 2/11/2024 at 3:00 pm, the facility Administrator stated the facility had 12 of 13 resident rooms that did not meet the 80 square feet per resident requirement and will continue to request a room waiver for the rooms. During a review of the room waiver request dated 2/20/2024, the request indicated the facility was requesting a waiver for Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14. The room waiver request indicated the 12 rooms had four (4) beds to a room and all rooms measure 304 square feet each room. The room waiver request indicated basic medical equipment or appliance such as suction machine, oxygen, IV poles, walkers, wheelchairs can be accommodated. The room waiver request indicated these rooms allow for adequate space for nursing care, comfort, and privacy of the residents. The room waiver request indicated there was enough space for the resident to maneuver around in the rooms. The room waiver request indicated there was enough space to enter and exit the rooms without hazard. The room waiver request indicated, despite the room requirements not being met, the residents' care and comfort will not be compromised. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555107 If continuation sheet Page 16 of 16