Other·December 6, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED DATE: April 24, 2018 The following reflects the findings of the Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Federal ID: 35893 28074 Total Resident Population: 44 Total Resident Sample: 11 and 2 Randomly Selected Residents Highest Scope and Severity: G

F225 SS=E INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 11/17/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or 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: 3TR311 Facility ID: CA950000077 If continuation sheet 1 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 2 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 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 ensure that two facility staff members were adequately trained for reporting abuse. A charge nurse (11 p.m. - 7 a.m.) and social service director did not know all agencies to report abuse. This deficient practice had the potential to underreport all alleged cases of resident abuse. Findings: During an interview on 10/28/17, at 7:20 a.m., licensed vocational nurse (LVN 2, 11 p.m. - 7 a.m. shift) did not state that abuse or cases of alleged abuse must be reported to Department of Public Health (DPH). During an interview on 10/28/17, at 8:30 a.m., Social Services Director (SSD) was unable to state that abuse or cases of alleged abuse must be reported to DPH. On 10/29/17, at 10 a.m., the Administrator stated that abuse or suspected abuse must be reported to DPH, along with the Ombudsman and local law enforcement.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l) FORM CMS-2567(02-99) Previous Versions Obsolete

F309 Event ID: 3TR311 11/18/2017 Facility ID: CA950000077 If continuation sheet 3 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 4 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 physician's orders were followed for 1 of 11 sampled residents (Resident 2). A physician's order for a Registered Dietitian (RD) consult was not immediately acted upon. The deficient practice had the potential to result in developing complications that could lead to a possible decline in the residents' physical wellbeing and progress. Findings: Resident 3 was re-admitted to the facility on 8/30/17, with diagnoses that included diabetes mellitus (high sugar level in the blood) and amputation of left lower extremities with infection. The Minimum Data Set (MDS), a standardized assessment tool, dated 8/22/17, indicated the resident was able to understand others and make himself understood, and required extensive assistance from staff in performing activities of daily living. Review of the physician's order dated 10/6/17, indicated an order for a registered dietitian evaluation due to low level of albumin (a protein made by the liver that keeps fluid from leaking out of blood vessels, nourishes tissues, and transports hormones, vitamins, drugs, and substances like calcium throughout the body). Review of the laboratory result dated 10/4/17, indicated albumin level of 2.5, normal range was 3.5 to 5.7 g/dl. Review of the medical records indicated the RD notes were dated 10/27/17, without time indicated. During an interview on 10/27/17, at 8 p.m., Registered Nurse (RN) 1 did not know why the RD was not able to do the evaluation since she comes to the facility every Mondays. Review of the facility's policy and procedure, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 5 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 Making A Referral To The Consultant Dietitian, dated May 2007, indicated: When a resident is identified that requires an assessment by the Registered Dietitian, a communication form is completed by the nurse and routed to the Dietary Service Supervisor. It is the responsibility of the DSS to provide the Registered Dietitian with the names of residents who have been referred upon his/her visit.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 11/18/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 6 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 by: Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent falls for one of 13 sample residents (Resident 2), who was assessed as high risk for falls by failing to: Implement the plan of care that Resident 2 was at risk for falls and injury, therefore needing extensive assistance (resident involved activity, staff provide weight bearing support) in all of her activities of daily living and maintain visual checks when up in a wheelchair, when necessary. Certified Nursing Assistant (CNA 1) left Resident 2 unattended in the bathroom while in a wheelchair and fell when Resident 2 was trying to wheel herself out of the bathroom. As a result of this failure, Resident 2 sustained swelling, bruising, and skin tear to the left forehead with active bleeding that needed to be cauterized (burn the skin or flesh of a wound with a heated instrument or caustic substance) to stop the bleeding . Findings: A review of the Admission Record indicated Resident 2 was readmitted to the facility on 10/2/17, with diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive lung disease characterized by long term poor airflow); bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs); and abnormalities of gait and mobility. Review of the facility's Resident Admission Assessment dated 10/2/17, indicated Resident 2 required extensive assistance (with one person assist) in physical functioning that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 7 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 included: bed mobility, transfer, walking, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene, and bathing. A review of the initial and quarterly Minimum Data Set assessment dated 7/20/17 and 10/20/17, indicated Resident 2 had the ability of making self understood and ability to understand others. A review of functional status for activities of daily living (ADL) indicated. Resident 2 required extensive assistance during transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. A review of the Resident Care Plan, dated 10/3/17, indicated Resident 2 was at risk for falls/injuries, gait (manner of walking) imbalance, and needs assist extensive assistance with activities of daily living (ADLs). Resident 2 was also high risk for fractures (broken bones) due to osteoporosis (bones weaken and fracture [break] more easily), risk of unexplainable fracture and recent hospitalization. The care plan goals indicated will implement safety interventions to minimize injury potential. The care plan nursing approaches included to assess and observe level of awareness and judgment; maintain visual check when up in a wheelchair and when in bed. A review of the Licensed Nurse's Notes indicated on 10/20/17 at 1 p.m., Resident 2 was found lying on the floor in a supine position (lying with the face upward). The licensed notes also indicated the following: The physician examined the resident, had no new orders, resident able to recall and describe the incident, alert and oriented x 4 (a person's awareness of herself, those around her, her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 8 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 location and the date and time), with equal and strong bilateral (both) hand grip, able to move all extremities (hands and feet). The notes also indicated that Resident 2 sustained a skin tear to the left side of forehead, 0.5 centimeters (cm) x 1 cm, with minimal bleeding and swelling noted with deep purple discoloration to surrounding skin, continue neurological checks (the assessment of motor responses, especially reflexes, to determine whether the nervous system is impaired ) as ordered, no changes to baseline. The licensed notes indicated that at 2 p.m., on the same date, Resident 2 was seen by the facility's wound consultant for the skin tear. Skin tear was noted with active bleeding and was cauterized (burn the skin or flesh of a wound) with a heated instrument or caustic substance) typically to stop bleeding or prevent the wound from becoming infected. During an interview with the director of nursing (DON) on 10/26/17, at 6:30 p.m., she stated that Resident 2 fell in the bathroom. The DON stated that according to the certified nurse assistant (CNA) 1, she left Resident 2 in the bathroom unattended because CNA 1 forgot something, when CNA 1 came back she found Resident 2 on the floor. On 10/27/17, at 6 p.m., Resident 2 was observed lying in bed. Resident 2 had a dressing on her left forehead. During a concurrent interview, Resident 2 stated "the wheelchair threw me off when I was coming out of the bathroom." Resident 2 added that she did not know where the nurse (CNA 1) went at that time. During an interview on 10/27/17 at 7:20 p.m., the Director of Staff Developer (DSD) stated Resident 2 was assessed as needing extensive assistance in bed mobility and transfer and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 9 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 CNAs are not to leave residents unattended. The DSD also stated that before the start of shifts, all staff meet for "huddles" (brief daily discussion) to keep them informed of the level of assistance each resident required. The DSD stated she did not know why CNA 1 left Resident 2 unattended in the bathroom in the wheelchair. She also stated that extensive assistance means staff are not supposed to leave resident alone during ADL activities. During an interview with the Director of Rehabilitation (DR) on 10/28/17, at 9 a.m., she stated that Resident 2 was not supposed to be left unattended, because "she needs extensive assistance with her ADLs." The DR added that Resident 2 cannot be left unattended while doing her ADLs. A review of the facility IDT Accident/Incident Review, dated 10/20/17, indicated CNA 1 assisted Resident 2 to the bathroom to brush her teeth and left the resident with instruction to call CNA 1 when Resident 2 is finished but that day Resident 2 did not call. According to Resident 2, her wheelchair got stuck on the door on her way out, and she fell forward. During a telephone interview with CNA 1 on 10/30/17, at 2:50 p.m., with the DSD as the interpreter, she stated that it had been the routine for her to set Resident 2 in the bathroom in her wheelchair, so she can brush her teeth, then leave her to make her the bed. CNA 1 stated that, "On 10/20 17, around 10 a.m., during the morning care, Resident 2's towel got wet and CNA 1 got out of the room to get Resident 2 a clean and dry towel. "I told resident to wait for me but, when I turned around, I saw her on the floor". "It happened so fast." CNA 1 was asked if she was aware what level of care Resident 2 received, CNA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 10 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 stated extensive assistance because she provides perineal (region between the posterior vulva junction and the anus in females) care, combing hair, and dressing. CNA 1 also stated that she was not aware that she could not leave the resident alone in the bathroom.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 11/18/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 11 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to properly indicate the use of medications for 3 residents (Resident 4, 6 and 9) in a total sample of 11. a. For Resident 4, observed with upper extremity tremors due to use of Risperdal. b. For Resident 6 behavior monitoring for Remeron (anti- depressant medication) not specific c. For Resident 9, there was no adequate indication to increase Abilify (anti-psychotic medication) and no indicated behavior for Ambien (medication for insomnia). These deficiencies had the potential to affect the residents treatment by administering potentially unnecessary medications. Findings: a. The "Admission Record" Resident 6 was admitted to the facility on 9/11/17, with the diagnoses that included Parkinson's disease (progressive disease of the nervous system) and muscle weakness. The Minimum Data Set (MDS- standardized assessment and care planning tool) dated 9/18/17, indicated Resident 6 had poor memory recall but was able to make self understood. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 12 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 resident required extensive assistance with one person physical assist in transfers, dressing and toilet use. The physician's order dated 10/23/17, indicated to give Remeron 15 milligrams (gm) orally every day for depression. The order did not indicate the behavior manifestation to monitor. On 10/28/17, at 5:10 p.m. during an interview with licensed vocational nurse (LVN 4) stated the order should have been clarified to include the behavior manifestations. b. A review of the Record of Admission indicated Resident 4 was admitted to the facility on 5/10/17, with diagnoses that included edema, schizophrenia (severe brain disorder in which people interpret reality abnormally). The Minimum Data Set (MDS-a standardized assessment and care planning tool), dated 6/14/17, indicated the resident was able to make self- understood, able to understand others, and required limited assistance with daily activities. A review of the clinical record revealed a physician's order dated 5/10/17, indicated to administer Risperdal (antipsychotic medication) 2 milligram (mg) for schizophrenia manifested by delusional false accusation about people/staff stealing her things every shift. The physician also ordered to monitor TCAP, TTardive dyskinesia (disorder that results in involuntary, repetitive body movements); Ccognitive/behavior impairment (decreased mental); A- Akathisia (movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or keep still, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 13 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 complain of restlessness, fidget, rock from foot to foot, and pace.) and P- Parkinsonism (rigidity and tremors) . The resident's care plan dated 5/10/17, Psychotropic Medication indication did not include the monitoring of the medication side effects. Documentation on the nursing notes did not indicate any behaviors and side effects. During observation on 10/27/17, at 8 p.m., during dinner time, Resident 4 was observed calm and quiet in her room. Also observed were tremors of both hands. During a concurrent interview, Resident 4 stated that she was not able to recall when the tremors started. During another observation on 10/28/17, at 9 a.m. with RN 1, the resident was lying in bed. The resident was again observed with tremors to both hands. During this observation, RN 1 was asked if she observed anything about the resident. RN 1 stated that tremors are adverse reactions from the use of psychotropic medications. RN 1 stated that she would notify the physician immediately. A review of the facility's Psychopharmaceutical Summary Sheet forms with the DON, dated 5/10/17 to 9/30/17, zero (0) behaviors or events and zero side effects all three shifts. Further review of the clinical records also indicated no documentation that the resident's physician was notified of the side effects/adverse reactions. The facility's policy and procedure, General Guidelines for the Use of Psychoactive Medication, dated November 2016, did not include the monitoring of the following side effects to the Attending Physician: extrapyramidal effects (EPS-a group of side FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 14 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 effects associated with antipsychotic medications. EPS include parkinsonism, akathisia (restlessness), dystonia (involuntary contractions of muscles) and tardive dyskinesia (Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements that includes grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking.) c. Resident 9 was admitted to the facility on 7/20/17, with diagnoses that included muscle weakness, hypertension, and muscle wasting. The Minimum Data Set (MDS), a standardized assessment tool, dated 7/27/17, indicated the resident usually understood others and usually made self understood, and required extensive to total assistance with most activities of daily living. A physician's order dated 8/9/17, indicated to administer Ambien 5 mg by mouth as neededinsomnia. A review of a care plan dated 7/20/17, indicated a problem of alteration in sleep patterns related to insomnia. The care plan indicated Resident 9 was on hypnotic (medication to induce sleep) therapy related to insomnia. The care plan goal indicated the resident would be free of acute complications and would receive maximal benefit from the medication daily for three months. The nursing interventions included to attempt to identify the cause of insomnia and try to resolve it, and to encourage the resident to follow a regular sleeping pattern. During an interview with the resident on 10/28/17, at 3 p.m., Resident 9 was confused and was not able to participate in the interview. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 15 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 During an interview with the DON on 10/28/17, at 3:45 a.m., she reviewed the clinical record and stated she was unable to find documentation of an adequate indication for the use of Ambien. She stated that she would notify the physician immediately.

F431 SS=E DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 11/18/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 16 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed: to have two licensed staff sign off the controlled medication log; a licensed staff left a medication unattended during medication observation. These deficient practices had the potential to result in inaccurate accounting of medications. Findings: During inspection of the medication storage on 10/26/17, at 5:50 p.m. with licensed vocational nurse (LVN 1), the emergency kit for oral medications was opened on 10/20/17, with two tablets of norco (pain medication) 5/325 milligrams removed and not replaced. Upon inspection of the emergency kit for intravenous FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 17 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 medications (medications infused through the vein), ceftriaxone (antibiotic medication) 1 gram and 1 hydration bag 100 milliliters were removed on 10/20/17, and not replaced. LVN 1 stated that whoever removes the medications was responsible for calling the pharmacy to have it replaced. During a review of the controlled medication log with registered nurse (RN 2) on 10/26/17, at 7: 50 p.m. the log indicated there was only one licensed staff signing off the controlled medication log on 9/24/17, at 3 p.m., 10/25/17, at 3 p.m. and 10/26/17, at 7 a.m. and 3 p.m. During an interview on 10/26/17, at 7:55 p.m., RN 1 stated that the controlled medication log should be checked by two licensed nurses and signed off by both. During a medication observation on 10/27/17, at 5: 40 p.m., (RN 1) left metoprolol (blood pressure medication) unattended to wash her hands inside randomly selected resident's (RSR 12) bathroom. Afterwards she acknowledged that medications should be secured and not left unattended. The facility's policy and procedure titled "Medication Administration" dated 2/2013, indicated the medication cart was kept closed and locked when out of sight of the medication nurse.

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 11/18/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 18 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 19 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interviews and record review, the facility failed to ensure that infection control practices were implemented in the facility for two of 13 sample residents (2 and 7). For Resident 2, the oxygen set had not been replaced in over 2 weeks in accordance to the facility's policy and procedure. The oxygen (O2) set was not labeled or dated for Resident 7. This deficient practice has the potential to cause infection to already compromised residents. The staff failed to disinfect the glucometer machine before placing it back in the medication cart and perform hand hygiene after removing gloves. These deficient practices have the potential to transmit infection to other residents. Findings: a. During the initial tour on 10/26/17, at 6 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 20 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 with the director of nursing (DON), Resident 2 was observed resting in bed. An oxygen concentrator (a portable device used to provide oxygen therapy to a patient at substantially higher concentrations than the levels of the room air) was observed at the bedside, with the oxygen set [humidifier, tubing and nasal cannulas (a plastic tube which fits behind the ears, and a set of two prongs which are placed in the nostril to deliver oxygen)] was observed dated 10/12/17. On 10/26/7, at 7:30 p.m., during an interview with the DON, she stated the oxygen was for Resident 2, but was not aware that the oxygen set was dated 10/12/17. A review of the facility's policy and procedure titled, "Oxygen Therapy," August 2010, indicated to replace the oxygen humidifier every 7 days or sooner if the bottle is empty. It also stated to label and date the humidifier. b. During the medication pass observation on 10/27/17, at 4:40 p.m., LVN 1 was observed taking the glucometer (or blood glucose monitoring device used to test the amount of blood glucose (sugar) in the blood) from the medication cart drawer. LVN 1 cleaned the glucometer with his gloves on. LVN 1 took the glucometer to Resident 2's room and took a sample of Resident 2's blood. After the procedure, LVN 1 returned to the medication cart and placed the glucometer machine back to one of the drawers without wiping it down. LVN 1 then removed his gloves and proceeded in preparing Resident 2's medications without washing his hands. At 5:20 p.m., LVN 1 removed the unclean blood glucometer, wiped it down with a sanitizing wipes with gloves on. LVN 1 took the glucometer to Resident 1's room and used the glucometer. After using the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 21 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 glucometer on Resident 1, LVN 1 placed the uncleaned glucometer back to the medication drawer where all the residents' medications and supplies were stored. LVN 1 removed his gloves and prepared Resident 1's medications without washing his hands. According to Centers for Disease Control (CDC), Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 6/8/17, indicated, whenever possible blood glucose meters should not be shared. If the device must be shared, the device should be cleaned and disinfected after every use. It also stated: Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of Hepatitis B virus (HBV) or have put persons at risk for infection include: 1. Using fingerstick devices for more than one person 2. Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses 3. Using insulin pens for more than one person 4. Failing to change gloves and perform hand hygiene between fingerstick procedures During an interview with Director of Nursing (DON) on 10/27/17, at 8 p.m., she stated the glucometer should be cleaned and sanitized before and after use and before placing back in the medication drawer. c. During initial tour with licensed vocational nurse (LVN 1) on 10/26/17, at 6:15 p.m., Resident 7 was observed in bed with the nasal cannula (tube that delivers oxygen to the resident through the nares) tubing touching the floor and was not dated. LVN 1 then retrieved another nasal cannula. The Admission Record for Resident 7 indicated the resident was re-admitted on 10/3/17, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 22 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 diagnoses of chronic obstructive pulmonary disease (COPD- lung diseases that block airflow and make it difficult to breathe), and hypertension (high blood pressure). The Minimum Data Set (standardized assessment and care planning tool) for Resident 7 dated 10/9/17, indicated the resident's cognition was intact. Resident 7 needed supervision and set-up help only for eating and walking. During an interview with director of staff development (DSD) on 10/29/17, at 9 a.m., she confirmed the oxygen tubing should have been changed due to infection control. Furthermore she added the oxygen tubing could be changed as needed and dated.

F456 SS=E ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION CFR(s): 483.90(d)(2)(e)

F456 11/18/2017 (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. This REQUIREMENT is not met as evidenced by: Based on observation interview and record review, the facility failed to maintain the resident's room and assistive equipment. This had the potential to affect the resident's quality of life. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 23 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 During an environmental tour on 10/28/17, from 11:00 a.m. to 12:30 p.m. with the maintenance supervisor the following was observed: 1. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 14 were observed with dirt and cobwebs on or nearby the sliding glass doors. 2. Room 2's wall paper and floor board were peeling. 3. Rooms 3 and 10 had no bathroom vent in restroom, and room 14's bathroom's vent was not working. 4. Room 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14 had 1/2 inch opening at the bottom of the window screen of the sliding door. In room 6 there were multiple ants found inside the room 6 and multiple dead ants on the sliding door tracking. 5. Missing blinds in room 1, 3, 4, and 14. 6. Brown spots on the ceiling in the medications room and room 8. 7. No daily water temperature log for May 2017, June 8-31, July 2017. The maintenance supervisor acknowledged and stated it would be fixed. The facility's policy and procedure titled "Interior Maintenance" and dated 3/1/16, indicated the facility should maintain all interior surfaces fixtures and equipment for both residents and employees. b. On 10/27/17 at 11:36 a.m., Resident 4 was observed lying on the bed sleeping. The resident's wheelchair was placed in front of the bed and the left arm rest had torn/cracked leather and exposed foam. During an interview with the Social Service Designee (SSD) on 10/28/17, at 10 a.m., she stated that the facility had attempted to replace the wheelchair several times, but Resident 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 24 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 had refused and had been non -compliant. When asked for the documentation of their attempts to replace the wheel chair, the SSD also stated she did not document the resident's refusal to replace the wheelchair.

F458 SS=B BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.90(e)(1)(ii)

F458 11/18/2017 (e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide bedrooms which must measure at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 12 of 13 bedrooms. Rooms 1, 2, 3, 4, 5, 6 , 7 ,8, 9, 10, 11, 12 and 14 did not meet the minimum square footage for these bedrooms. The rooms with insufficient square footage could lead to possible inadequate nursing care to the residents in these rooms. Findings: On 10/26/17, at 8 p.m. during the entrance conference, the Director of Nursing stated that the facility had 12 of 13 resident room variances in effect and that the facility will continue to request variance for the rooms. On 10/26/17, between 5:30 p.m. and 6:30 p.m., during initial tour, it was observed that there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 25 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 were 12 of 13 resident rooms (rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14) that did not meet the minimum requirement of 80 sq. ft. per resident in multiple resident rooms. It was noticed that most of the residents in these rooms were able to move in their wheelchairs while inside the room. There was space for the beds, side tables, dresser closets and any other medical equipment. The facility staff had limited space to provide care to these residents. On 10/27/17, at 8 a.m., the Administrator submitted a room waiver for the 12 rooms that did not meet the minimum requirement of 80 sq. ft. per resident in multiple resident rooms. The room waiver indicated there were four beds in all 12 rooms and the square footage was 304 sq. ft. each room. The minimum square footage for a 4- bedroom is 320 sq. ft. These 12 resident rooms were below the minimum requirement by 16 sq. feet and could lead to possible inadequate nursing care to the residents in these rooms.

F463 SS=D RESIDENT CALL SYSTEM ROOMS/TOILET/BATH CFR(s): 483.90(g)(2)

F463 11/18/2017 (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area (2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 26 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 Based on observation and interview the facility failed to maintain the resident call light system in good repair for resident use. This deficient practice placed the resident's safety at risk. Findings: a. During the initial tour on 10/26/17, at 6 p.m., with the director of nursing (DON), in room 1 bed D, the call light system was not functioning properly. The DON attempted 3 times to check the call light but the system did not work. The DON was informed that there was no light observed over the door, and no sound was observed coming from the call light panel near the nursing station. The DON stated that she would notify the Maintenance staff immediately. b. During an environmental tour with the maintenance supervisor at 12:30 p.m. on 10/29/17, shower room call light was two and a half feet away from the resident's reach. The maintenance supervisor acknowledged the call light was not within reach and stated he would find something to anchor the string connected to the call light so the light could be reached by the resident while in the shower.

F518 SS=D TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 11/18/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 27 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 Based on interview and policy review, two of eight facility staffs, licensed vocational nurse (LVN 2) and dietary supervisor (DS) failed to demonstrate emergency preparedness knowledge. a. LVN 2 from the 11 p.m. to 7 a.m. shift was not aware of the fire extinguisher locations. This failure had the potential to place residents at risk for danger in case of a fire. b. DS was not aware of the emergency water locations. Two out of eight staff members were not aware of where the emergency equipment and water were located. This failure had the potential to affect the residents safety in the event of a disaster. Findings: a. During an interview with LVN 2 on 10/28/17, at 7:20 .a.m., LVN 2 could not recall the fire extinguisher locations in the event of an emergency. A review of the facility's undated policy and procedure titled "Disaster Preparedness" indicated that staff in all departments should be familiar with firefighting appliances such as fire extinguishers. b. During an interview with the DS on 10/28/17, at 6:45 a.m., DS was asked to locate where the facility's emergency water was. DS was not able to indicate the location but stated that it was posted on the wall. The DS was unable to state the location of the emergency water. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 28 of 29 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: _______________ 555107 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA CARE CENTER 3541 Puente Ave 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 On 10/28/17, at approximately 8 a.m., the DS, with the Regional Manager, was asked to state the location of the emergency water. The DS then stated that she had not been informed and had not been shown where the emergency water was located. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3TR311 Facility ID: CA950000077 If continuation sheet 29 of 29