Other·July 26, 2019

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 California Department of Public Health during a complaint investigation. Complain number: CA00627215. Representing the Department: HFEN # 36231. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00627215.

F695 SS=G Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with the needed respiratory (relating to or affecting respiration [breathing]) care including: 1. Failure to follow Resident 1's care plan for 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: 9WP411 Facility ID: CA950000018 If continuation sheet 1 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 respiratory function by not taking the respiratory rate and lung sounds during assessment for shortness of breath (SOB). 2. Failure to notify Resident 1's physician on 3/1/19, when Resident 1's shortness of breath required a non-rebreathing (NRB) mask (a device that deliver a high concentration [100%] of oxygen [O2]). 3. Failure to take Resident 1's vital signs (reflect essential body functions, including heart rate, respiratory rate, temperature, and blood pressure) and assess Resident 1's inability to sleep as a result of being afraid something would happen if he closed his eyes. 4. Failure to implement the facility's policy on pulse oximetry (a test used to measure the oxygen level [oxygen saturation, measurement of oxygen concentration in the blood and normal range 90% to 100%] of the blood) by not reporting any abnormal results to the physician and policy on oxygen therapy by not consistently indicating the flow rate of oxygen therapy administered to Resident 1. As a result, on 3/2/19, Resident 1 experienced severe respiratory distress, cardiopulmonary arrest (heart attack - the heart stop working) requiring cardiopulmonary resuscitation (CPR a lifesaving technique useful in many emergencies in which someone's breathing or heartbeat had stopped), paramedics (emergency rescue team) transferred Resident 1 to General Acute Care Hospital 2 (GACH 2), where he died on 3/3/19. Findings: A record review of the Resident 1's Record of Admission indicated Resident 1 was admitted to the facility, on 2/28/19 at 12:46 a.m., with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 2 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease that makes breathing difficult) and pneumonia (lung infection). A record review of the Resident 1's Nursing Admission Assessment form dated 2/28/19, timed at 12:46 a.m., indicated Resident 1 had rhonchi (continuous low pitched, rattling breath sounds often resemble snoring) and the breathing was irregular. Resident 1 had mild labored (difficulty) breathing with oxygen at two liters per minutes (2 L/min, unit of measurement). A record review of the Resident 1's Care Plan developed on admission (2/28/19) for Resident 1's impaired respiratory function related to diagnoses included in the approaches assessing the respiratory rate, presence of shortness of breath, lung sounds, chest pain, congestion, coughing, weakness, edema (swelling) in hands and feet, activity intolerance, and checking pulse oximetry. A record review of the Resident 1's Admission Orders dated 2/28/19, indicated: - Apply Resident 1 a Bi-level Positive Airway Pressure (BIPAP - a type of ventilator that helps with breathing and is administered with oxygen) from 9 p.m. to 7 a.m. - Administer nebulization (small machine that turns liquid into mist) with Duoneb (medication to open the airway - respiratory treatment) three milliliters (ml, unit of measurement) via Hand-Held nebulizer (HHN- small machine that turns liquid medicine into a mist) every six hours while awake and every two hours as needed (PRN) for shortness of breath. - Apply oxygen at 2 L/min via nasal cannula (N/C - a plastic tubing with two prongs to fit in the nostrils). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 3 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 A record review of the Resident 1's Physician Orders for Infusion Therapy, dated 2/28/19, indicated the physician orders for Flagyl (antibiotic medication) 500 milligram (mg, unit of measurement) every eight hours for colitis (an inflammation of the colon) for seven (7) days given intravenously (IV- medication administered directly into the vein), and Rocephin (antibiotic medication) 1 gram (gr unit of measurement) every 24 hours for seven days for pneumonia. A record review of the Resident 1's Nursing Notes, dated 3/1/19, had the following entries by Licensed Vocational Nurse 1 (LVN 1): At 9:30 a.m., LVN 1 documented Resident 1 complained of shortness of breath, the oxygen saturation was 92% (normal range 90% 100%) and the heart rate was 80 (normal range 60 to 100 beats per minute [bpm]). Resident 1 was administered hand held nebulizer (HHN, breathing treatment medication). At 10:45 a.m., LVN 1 documented Resident 1 had shortness of breath during physical therapy (PT) treatment. LVN 1 applied 100% oxygen NRB mask. LVN 1 left Resident 1 with PT when Resident 1's oxygen saturation was 90% and heart rate was 96 bpm. At 11:45, LVN 1 administered HHN respiratory treatment for shortness of breath. After the HHN, the heart rate was 82 bpm, oxygen saturation was 92%, and on N/C (no O2 flow rate documented). At 12:30 p.m., LVN 1 documented Resident 1 refused to eat lunch or anything by mouth. Resident 1 had N/C (no O2 flow rate documented). At 1:50 p.m., LVN 1 administered HHN respiratory treatment for shortness of breath. After the HHN, the heart rate was 78 bpm and oxygen saturation was 96%. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 4 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 A record review of the Resident 1's Nursing Notes, dated 3/1/19, had the following entries by Registered Nurse 1 (RN 1): At 1:40 p.m., Registered Nurse 1 (RN 1) documented Resident 1 was requesting for breathing treatment, heart rate was 78 bpm, and O2 saturation was 96%. RN 1 documented Resident 1 had no shortness of breath, coughing, and congestion. At 3:15 p.m., RN 1 documented Resident 1 was receiving oxygen at 2 L/min and did not have shortness of breath. A record review of the Nursing Notes dated 3/1/19, timed at 4 p.m. and 6 p.m., indicated LVN 3 documented Resident 1 was receiving oxygen at 2 L/min and did not have shortness of breath. A record review of the Nurses Notes, dated 3/02/19, had the following entries by LVN 4: At 2:30 a.m., LVN 4 documented Resident 1 was anxious, and stated he (Resident 1) was unable to sleep and scared to close his eyes. LVN 4 documented, "Resident added that something might happen." LVN 4 did not document checking Resident 1's lung sounds, O2 saturation, and vital signs. At 5 a.m., LVN 4 documented no coughing and congestion noted. A record review of the Nursing Notes, dated 3/2/19, had the following entries by RN 2: At 8 a.m., RN 2 documented Resident 1 was pale looking, had marked abdominal distention, and did not sleep well last night. At 10:45 a.m., RN 2 documented Resident 1 had shortness of breath, had abdominal pain, the oxygen saturation was 88%, the blood pressure was 68/45 millimeters of mercury (mmHg, unit of measurement, and normal range more than 120 over 80 and less than 140 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 5 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 over 90 [120/80 - 140/90]), and the heart rate was 80 bpm. Resident 1 was placed on 100% NRB mask. RN 2 called at 8 a.m. and at 10 a.m., Resident 1's physician to ask for a sleep aid medication. Resident 1's physician did not return RN 2's calls. At 10:50 a.m., RN 2 documented Resident 1 was more pale, was breathing through his mouth, and both hands had weak grip (ability to squeeze hand). At 10:58 a.m., RN 2 documented calling 911 (paramedics). At 11:06 a.m. RN 2 documented Resident 1 stopped breathing, had no pulse (heart rate), and CPR was initiated. A record review of the Ambulance Service Patient Care Report dated 3/2/19, timed at 11:07 a.m., indicated Resident 1 had agonal breathing (gasping respiration) with no pulse upon paramedics' arrival. Paramedics continued CPR. A record review of the GACH 2 Emergency Department (ED) History & Physical (H&P), dated 3/2/19 at 11:49 a.m., indicated Resident 1's physical exam of the respiratory was coarse breath sounds (small clicking, bubbling, or rattling sounds in the lungs) bilateral (both, left and right lungs). Resident 1 was intubated (a tube - endotracheal tube [ET], inserted through the mouth to assist with breathing) at 11:55 a.m. The portable chest X-ray (diagnostic exam to evaluate the lungs) indicated Resident 1 had moderate bilateral congestion with right lower lobe infiltrates (any blockage to an air space in a lung caused by the build-up of a substance that's foreign to the lung). A record review of the GACH 2 Death Summary Report indicated date of admission was 3/2/19, and date of death was 3/3/19. The report indicated Resident 1 was intubated in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 6 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 the ED, brought to Surgical Intensive Care Unit (SICU), continued to worsen, and died on 3/3/19. A record review of the Certificate of Death indicated the death date was on 3/3/19, at 2:45 a.m., and Resident 1's cause of death was cardiopulmonary arrest, septic shock (serious condition that occurs when a body-wide infection leads to dangerous low blood pressure), and ischemic colitis (blood flow to part of the large intestine is reduced due to narrowing or blocked blood vessels). During an interview, on 3/5/19 at 7:18 a.m., Certified Nursing Assistant 1 (CNA 1) stated she worked 7 a.m. to 3 p.m. shift on 3/1/19, and Resident 1 had on and off breathing problem, and CNA 1 notified LVN 1. CNA 1 stated on 3/2/19 at the start of the shift (7 a.m. to 3 p.m.), Resident 1 kept telling her (CNA 1) he could not breath. During an interview, on 3/6/19 at 7:23 a.m., LVN 1 stated on 3/1/9, Resident 1 improved with the NRB mask and its use did not require notification to Resident 1's physician or to RN 1. LVN 1 stated on 3/2/19 at 10:50 a.m., CNA 1 reported Resident 1's stomach was hurting and was short of breath. LVN 1 stated CNA 1 notified RN 2. During an interview on 3/6/19 at 9:58 a.m., RN 2 stated, on 3/02/19 at 10:45 a.m., CNA 1 had reported Resident 1 had SOB. RN 2 stated Resident 1 was purse lip breathing (a breathing technique that consists of exhaling through tightly pressed (pursed) lips and inhaling through the nose with the mouth with O2 saturation of 88% on O2 2L/min via N/C, and was pale. RN 2 stated a 100% non-rebreathing mask was administered, but Resident 1's color was becoming more pale, continued breathing through his mouth, and both hand grips were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 7 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 weak. RN 2 stated she called 911. RN 2 stated she did not recall assessing Resident 1's lung sounds and vital signs. During an interview, on 5/28/19 at 3:20 pm., LVN 4 stated, on 3/2/19 from 11 p.m. to 7 a.m., Resident 1 was nervous, could not sleep, scared to close his eyes, and stating something might happen. LVN 4 stated Resident 1 was not SOB. LVN 4 stated if Resident 1 was in any distress, he would check the vital signs, and for SOB, he would check the O2 saturation. LVN 4 stated physician was not notified. A record review of the facility's policy on Change in Resident's Condition and Status dated 1/2012, indicated the facility shall promptly notify the resident, his or her attending physician of changes in the resident's medical/mental condition and/or status including changes in level of care. A record review of the facility's policy on Measuring Respiration, undated, indicated the purpose was to determine how many times the resident breathes in and out. The reporting and documentation included respiratory rate, if respirations were easy or labored, and if the respiration was noisy. A record review of the facility's policy on Oxygen Therapy dated 7/2018, indicated oxygen will be administered as ordered by the physician or as an emergency measure until a physician's order can be obtained. The person performing should record the following information: the date, time, flow rate or percentage, device used, oxygen saturation, assessment of resident's response, and date and time the therapy (oxygen) was discontinued. A record review of the facility's policy on Pulse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 8 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 Oximetry dated 11/2008, indicated pulse oximetry was to obtain and utilize the results of the oxygen saturation in the assessment of the resident's respiratory status or condition. Reporting any unusual observation to the physician and any failure of physician's orders to correct abnormal findings.

F713 SS=D Physician for Emergency Care Available 24 hrs F713 CFR(s): 483.30(d) §483.30(d) Availability of physicians for emergency care The facility must provide or arrange for the provision of physician services 24 hours a day, in case of emergency. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to have a physician available to respond to calls made by facility nurse regarding a resident for one of two sampled residents (Resident 1). The deficient practice resulted in no physician answering calls made by a facility nurse, on 3/2/19 at 8 a.m. and 10 a.m., for Resident 1. Findings: A review of the Resident 1's Record of Admission indicated Resident 1 was admitted to the facility, on 2/28/19 at 12:46 a.m., with the diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease that makes breathing difficult) and pneumonia (lung infection). The primary physician was Physician 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 9 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 A review of the Nurses Notes by Licensed Vocational Nurse 4 (LVN 4), dated 3/02/19 at 2:30 a.m., indicated LVN 4 documented Resident 1 was anxious and stated he (Resident 1) was unable to sleep and scared to close his eyes. LVN 4 documented, "Resident added that something might happen." LVN 4 documented will request for sleep aide for resident. A review of the Nurses Notes by Registered Nurse 2 (RN 2), dated 3/2/19 at 8 a.m., indicated RN 2 documented Resident 1 was, "Pale looking," had, "Marked abdominal distention," and did not sleep well last night. RN 2 informed Resident 1 and wife that the on call physician will be called for the sleeping aide. A review of the Nurses Notes by RN 2, date 3/2/19 at 10 a.m., indicated RN 2 documented a follow up call was made to Physician 1 regarding request for sleeping aide. During an interview on 3/6/19 at 9:58 a.m., RN 2 stated Physician 1 (Facility Medical Director), on 3/2/19, was out of town and Physician 2 was covering. RN 2 stated she had called the Physician 2 twice for a sleeping medicine but doctor did not respond. During an interview on 3/6/19 at 10:15 a.m., the Director of Nursing (DON) stated Physician 2 was covering for Physician 1, who was also the facility's Medical Director and Resident 1's primary doctor. During an interview, on 3/14/19 at 11:25 a.m., the DON stated this was something that the facility had to looked into if attending doctor and the medical director could not be reach. During a telephone interview, on 5/13/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 10 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 1:05 p.m., Physician 2 stated he did not know Resident 1 nor received a telephone call, on 3/2/19, regarding Resident 1. During a telephone interview on 5/13/19 at 2:05 p.m., RN 1 stated that doctor's office will notify the facility that such doctor will be out on vacation and/or will be off and another doctor will be covering during his absence. RN 1 stated the notification (physician coverage) will be posted to both nurse stations. During an interview on 5/13/19 at 2:10 p.m., the Administrator stated in the past, he had heard DON informing RN supervisor about doctor coverage during their absence. During a telephone interview, on 5/14/19 at 10:10 a.m., the DON stated Administrator was informed by Physician 1 that Physician 1 will be out of town, and Physician 2 would be covering during his absence. During an interview, on 5/28/19 at 3:20 p.m., LVN 4 stated on 3/2/19 during the 11 p.m. to 7 p.m. shift, Resident 1 was nervous, could not sleep because he was scared to close his eyes stating something might happen. LVN 4 stated the request of getting a sleeping aid medication was endorsed to the morning licensed nurse. A review of the facility's Medical Director Agreement, dated 10/1/14, indicated the Physician shall inform the Administrator of any extended periods (i.e, . one week or more) during which Physician will be unavailable due to vacation, professional meetings, or other personal or professional commitments. Physician shall have the right to engage a substitute physician ("Substitute") to perform the services required of Physician hereunder in Physician's place during such periods. The agreement indicated the Substitute meets all of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 11 of 12 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: _______________ 056466 (X3) DATE SURVEY COMPLETED 06/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIERRA VIEW CARE CENTER 14318 Ohio St Baldwin Park, CA 91706 (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 the qualifications required of Physician, and the Administrator gives prior written approval of such Substitute. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9WP411 Facility ID: CA950000018 If continuation sheet 12 of 12