Health inspection·January 23, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Nursing progress notes dated 9/24/2024 at 7a.m., the progress notes did not indicate Resident 1's PCP was notified of Resident 1's refusal to receive the insulin. During a review of Resident 1's MAR dated 9/24/2024 at 4 p.m., the MAR indicated Resident 1's blood sugar was 211 mg/dL and should have received 6 units of insulin. The MAR indicated Resident 1 refused insulin. During a review of Resident 1's Nursing progress notes dated 9/24/2024 at 4 p.m., the progress notes did not indicate Resident 1's PCP was notified of Resident 1's refusal to receive the insulin. During a review of Resident 1's Medication Administration Record (MAR) dated 9/24/2024 at 9 p.m., the MAR indicated Resident 1 had a blood sugar level of 219 mg/dL and should have received 6 units of insulin. The MAR indicated Resident 1 refused insulin. During a review of Resident 1's Nursing progress notes dated 9/24/2024 at 9 p.m., the progress notes did not indicate that Resident 1's PCP was notified of Resident 1's refusal to receive the insulin. During a concurrent interview and record review on 1/23/2024 at 2:31 p.m. with the Director of Nursing (DON), Resident 1's chart was reviewed. The DON stated that Resident 1's chart had a Change of Condition ([COC] a document prepared when changes or problems were identified, including notification of the PCP) dated 10/4/2024. The DON stated that a COC should have been created for Resident 1 on 9/24/2024 when Resident 1 refused to receive the insulin injections. The DON stated Resident 1's PCP was not notified when Resident 1 refused insulin injections on 9/24/2024. The DON stated if the PCP was notified, the PCP could have provided orders to help regulate (control according to rule) Resident 1's blood sugar. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, , dated 1/1/2012, the P&P indicated if a resident refused medication, the licensed nurse would notify PCP and document in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555112 If continuation sheet Page 2 of 6 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 555112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan to one of 3 residents (Resident 1), who refused to receive insulin (medicine for diabetes mellitus ([DM], abnormal blood sugar levels) injection on 9/24/2024, for the high blood sugar levels, as ordered by the physician. This failure had the potential that interventions Resident 1 would need will not be provided, resulting in poor quality care and complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included polyneuropathy (a condition where multiple nerves become damaged leading to problems with sensation, coordination, or other body functions) and Type 2 DM (when the body becomes resistant to insulin). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 9/29/2024, the MDS indicated that Resident 1 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for Activities of Daily Living (ADLs) such upper body dressing and required setup or clean-up assistance for ADLs such as oral hygiene. During a review of Resident 1's Order Summary report dated 1/23/2025, Resident 1's physician's order dated 9/22/2024 indicated Insulin Regular Human Injection Solution to inject as per sliding scale (a varied dose of insulin based on blood glucose level), subcutaneously (inject under skin) before meals and at bedtime, if the blood glucose levels are as follows (normal fasting blood sugar level is between 70 and 100 milligrams per deciliter (mg/dL). A normal blood sugar level two hours after eating is less than 180 mg/dL.): 70-150 = 0 units; 151-200 = 4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 12 units; 351-400 = 14 units. If above 400, give 16 units and call Medical Doctor (PCP). During a review of Resident 1'a Medication Administration Record (MAR), dated 9/24/2024, the MAR indicated Resident 1 refused to receive insulin on 9/24/2024 at 7 a.m., 4 p.m. and at 9 p.m. as ordered by the PCP. During a review of Resident 1's care plan titled, The resident has Diabetes Mellitus, dated 9/28/2024, the care plan did not indicate when Resident 1 refused to receive insulin medicine on 9/24/2024. During a concurrent interview and record review on 1/23/2025 at 2:31 p.m. with the Director of Nursing (DON), Resident 1's care plan was reviewed. The DON stated Resident 1 did not have a care plan that addressed Resident 1's refusal of insulin. The DON stated the care plan for refusal of insulin should have been initiated on 9/24/2024 to communicate to staff and provide guidance on further interventions. During an interview on 1/23/2025 at 2:50 p.m. with the DON, the DON stated the facility did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555112 If continuation sheet Page 3 of 6 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 555112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660 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 FORM CMS-2567 (02/99) Previous Versions Obsolete initiate a care plan or update Resident 1's care plan when Resident 1 refused to receive the insulin medicine. During a review of the facility's Nursing Manual, titled, Care Planning, dated 3/1/2024, the Nursing Manual indicated, it is the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflected the best practice standards for meeting the health and safety needs of the residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Event ID: Facility ID: 555112 If continuation sheet Page 4 of 6 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 555112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 meet professional standards of practice by failing to ensure one of three sampled residents (Resident 1), who was diabetic and who refused insulin (medicine for diabetes) injection, was monitored for any possible diabetic reactions which could be life-threatening. Residents Affected - Few This failure had the potential for Resident 1 to suffer complications from uncontrolled blood sugar levels that could lead to hospitalization and/or death. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included polyneuropathy (a condition where multiple nerves become damaged leading to problems with sensation, coordination, or other body functions) and Type 2 diabetes mellitus ([DM] a type of DM when the body becomes resistant to insulin). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 9/29/2024, the MDS indicated Resident 1 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for Activities of Daily Living (ADLs) such upper body dressing and required setup or clean-up assistance for ADLs such as oral hygiene. During a review of Resident 1's Order Summary report dated 1/23/2025, Resident 1's physician's order dated 9/22/2024 indicated Insulin Regular Human Injection Solution, to inject as per sliding scale (a varied dose of insulin based on blood glucose level), subcutaneously (inject under skin) before meals and at bedtime, if the blood glucose levels are as follows (normal fasting blood sugar level is between 70 and 100 milligrams per deciliter (mg/dL). A normal blood sugar level two hours after eating is less than 180 mg/dL.): 70-150 = 0 units; 151-200 = 4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 12 units; 351-400 = 14 units. If above 400, give 16 units and call Medical Doctor (PCP). During a review of Resident 1's Medication Administration Record (MAR), dated 9/24/2024, the MAR indicated Resident 1 refused to receive insulin on 9/24/2024 at 7 a.m., 4 p.m. and at 9 p.m. as ordered by the PCP. During a concurrent interview and record review on 1/23/2025 at 2:31 p.m. with the Director of Nursing (DON), Resident 1's nursing progress notes dated 9/24/2024 to 9/28/2024, and the MAR from 9/25/2024 to 9/28/2024 were reviewed. The DON stated the MAR indicated Resident 1 refused the insulin injections on 9/25/2024 at 7 a.m., on 9/26/2024 at 7 a.m. and on 9/27/2024 at 4 p.m. and at 9 p.m. The DON stated there was no documentation about Resident 1's refusal to take the insulin injection nor documentation that signs and symptoms of hyperglycemia (high blood sugar) such as headache, increased hunger, thirst, and frequent urination were monitored after Resident 1's refused the insulin. During a review of the facility's Nursing Manual titled, General, Diabetic Care, dated 1/1/2012, the Nursing Manual indicated, the Licensed Nurse should document clearly and consistently all diabetic monitoring and administration of medications. The Nursing Manual indicated, the nursing staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555112 If continuation sheet Page 5 of 6 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 555112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660 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 0658 Level of Harm - Minimal harm or potential for actual harm should monitor the resident for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia and initiate interventions, if necessary and notify the Attending Physician if signs and symptoms were present. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555112 If continuation sheet Page 6 of 6