Other·November 3, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an investigation of an Facility-Reported-Incident (FRI). Facility-Reported-Incident: 692277Substantiated. Representing the Department: #42200, HFEN The inspection was limited to the specific complaints / facilitiy-reported-incidents investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were written as a result of facility-reportedf-incident number 692277.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 10/19/2020 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report a humerus (long bone in the arm, that runs from the shoulder to the elbow) fracture of unknown cause to the state agency within 2 hours of receiving the X-Ray results for one of one resident (Resident 1). This deficient practice had the potential to result in an unidentified abuse or crime and failure to protect resident 1 from harm in the facility. Findings: A review of the Admission Record, indicated Resident 1 was admitted on 2/4/12 and readmitted on 6/13/20, with diagnoses including Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), hemiplegia (paralysis of one side of the body) affecting the left side, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pathological fracture (broken bone caused by a disease, rather than an injury) of left humerus and osteoporosis (condition in which bones become weak and brittle). A review of the Minimum Data Set ([MDS], a comprehensive standardized assessment and care screening tool) dated 3/14/20, indicated Resident 1 had severely impaired cognitive skills for daily decision-making and required extensive assistance for activities of daily living including bed mobility, transfer, dressing, toilet use and personal hygiene. On 9/9/20 at 11:45 a.m., during an interview and concurrent record review, Registered Nurse (RN 1) stated that on 6/10/20 Resident 1 had discoloration and swelling to the left upper arm with an unknown cause. RN 1 stated, an xray of the shoulder was done on 6/10/20 at 11:42 p.m. According to RN1, the X-Ray results on 6/11/20 at 12:21 a.m. indicated the resident had a fracture of the humerus. RN 1 stated the Director of Nursing (DON 1) was notified of xray result on 6/11/20 at 12:43 a.m. On 9/11/20 at 2:23 p.m. during an interview, Administrator (Admin 1) stated that after receiving the x-ray result for resident 1, the first thing that needed to be ruled out was abuse. Admin 1 stated that the fracture of unknown origin for the resident was reported to state agency on 6/11/20 at 3:25 p.m. and that it should have been reported to state agency as soon as possible or within 2 hours of identifying the injury however was not done. Admin 1 stated that it is important to report in a timely matter as a measure to maintain safety and ensure protection for the resident. A review of the facility's policy titled, "AbuseReporting and Investigations" revised 3/2018, indicated the facility will promptly report and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE allegations of resident abuse, mistreatment, neglect, injuries of an unknown source and suspicions of crimes. Reporting to CDPH of reasonable suspicion of crime against a resident and allegations of abuse within two hours of initial report within 2 hours.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/19/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to conduct visual checks at least every two hours and as needed per care plan for one of one resident (1). This deficient practice had the potential to lead fall/injury for Resident 1. Findings: A review of the Admission Record, indicated Resident 1 was admitted on 2/4/12 and readmitted on 6/13/20 with diagnoses including alzheimer's disease (A progressive disease that destroys memory and other important mental functions), hemiplegia (paralysis of one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE side of the body) affecting the left side, pathological fracture (broken bone caused by a disease, rather than an injury) of left humerus (long bone in the arm that runs from the shoulder to the elbow) and osteoporosis (condition in which bones become weak and brittle). A review of the Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool) dated 3/14/20 indicated Resident 1 had severely impaired cognitive skills for daily decision-making and required extensive assistance for activities of daily living including bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Fall Risk Data Collection dated 5/7/20, indicated Resident 1 was a high risk for fall. On 9/10/20 at 3:53 p.m., Certified Nurse Assistant (CNA 1) stated resident 1 needed a lot of assistance with two people to get up to the wheelchair and would try to get up by himself. CNA 1 stated he could not remember if he conducted t visual checks at least every two hours on the resident. On 9/11/20 at 11:32 a.m., during an interview and concurrent record review of care plan for potential for fall/injury related to cognitive deficit, poor decision making, unsteady gait, diagnosis including stroke, dementia, osteopenia, osteoarthritis dated 4/13/20 and revised on 5/7/20, MDS coordinator (MDS 1) stated resident 1's interventions included a visual check to be performed every 2 hours and as needed. On 9/11/20 at 2:44 p.m. Director of Nursing (DON 2) stated there was no documentation found to indicate visual checks every two hours FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and as needed was done for Resident 1 per careplan. DON 2 stated the importance of ensuring a visual check was completed for the resident per careplan is to ensure the resident was safe from injury. A review of the facility's policy titled, "Comprehensive Person-Centered Care Planning" revised 11/2018, indicated the facility will provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being.

F710 SS=D Resident's Care Supervised by a Physician CFR(s): 483.30(a)(1)(2)

F710 10/19/2020 §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. §483.30(a) Physician Supervision. The facility must ensure that§483.30(a)(1) The medical care of each resident is supervised by a physician; §483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to follow-up with the physician for medication recommendations to address osteoporosis (condition in which bones become weak and brittle) diagnosis for one of one sampled resident (Resident 1) This deficient practice had the potential to predispose Resident 1 to have recurrent pathological bone fractures. Findings: A review of the Admission Record, indicated Resident 1 was admitted on 2/4/12 and readmitted on 6/13/20 with diagnoses including alzheimer's disease (A progressive disease that destroys memory and other important mental functions), hemiplegia (paralysis of one side of the body) affecting the left side, pathological fracture (broken bone caused by a disease, rather than an injury) of left humerus (long bone in the arm that runs from the shoulder to the elbow) and osteoporosis. A review of the Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool) dated 3/14/20 indicated Resident 1 had severely impaired cognitive skills for daily decision-making and required extensive assistance for activities of daily living including bed mobility, transfer, dressing, toilet use and personal hygiene. On 9/9/20 at 11:45 a.m., during an interview, RN Supervisor (RN 1) stated that on 6/10/20 Resident 1 had discoloration and swelling to the left upper arm with an unknown cause. RN 1 stated an xray of the shoulder was done on 6/10/20 at 11:42 p.m. and resulted on 6/11/20 at 12:21 a.m. which indicated the resident had fracture of the humerus. RN 1 stated the resident had a history of arthritis and osteoporosis and that there were no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications to address osteoporosis prior and after the fracture sustained by the resident on 6/10/20. On 9/10/20 at 2:58 p.m. during an interview, Pharmacist (Pharmacist 1) stated the facility had not brought it up to the pharmacist to consult regarding medication for the resident's osteoporosis. On 9/10/20 at 5:10 p.m. during an interview, Primary Physician (MD 1) stated that he was not aware of the osteoporosis for Resident 1 and was not notified by the facility regarding this need for the resident. MD 1 stated he had spoken to DON who told him the information related to resident 1's fracture incident on 6/10/20. MD 1 stated he had ordered for pharmacy to recommend, dose and start medication for Resident 1 including Vitamin D, Calcium and/or fosamax. MD 1 stated he was not aware of the osteoporosis diagnosis and was not notified by the facility prior. MD 1 stated the importance of providing these medications to Resident 1 is to help prevent further progress of osteoporosis. On 9/11/20 at 11:32 a.m., during an interview and concurrent record review of x-ray of the left knee obtained on 5/1/20, Director of Nursing (DON 2) stated Resident 1 had osteopenia (thinning of bone mass) and had no medications initiated to address this. DON 2 stated it was important to communicate with the doctor if a need/diagnosis is not addressed because nurses know what was going on with the resident and are the ones to advocate to ensure the resident had the proper treatment. On 9/11/20 at 2:15 p.m., during an interview and concurrent record review of physican order dated 9/11/20, DON 2 stated covering physician (MD 2) had placed an order to start FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555112 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fosamax 70mg once a week, calcium+ vitamin D 500mg every day for osteoporosis. A review of the facility's policy titled, "Change of Condition Notification," indicated that the facility would promptly inform the resident's attending physician of changes in resident's condition that require a medical assessment, coordination, consultation and change in treatment plan. Licensed nurse will notify the resident's attending physician when there is a significant change in the resident's physical status such as when there is a need to alter treatment (e.g based on lab/xray results). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8I7V11 Facility ID: CA940000044 If continuation sheet 9 of 9