Sierra View Care Center

During a review of Resident 100's History and Physical (H&P) dated 4/20/2026, the H&P indicated Resident 100 had the capacity to make medical decisions.

During a review of Resident 100's Minimum Data Set (MDS- a resident assessment tool) dated 4/22/2026, the MDS indicated Resident 100 had moderately impaired cognition (ability to understand and process information).

The MDS indicated Resident 100 required supervision from staff with eating.

The MDS indicated Resident 100 required moderate assistance (helper did less than half the effort) from staff with oral hygiene and personal hygiene.

The MDS indicated Resident 100 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and mobility.

During a review of Resident 100's Order Summary Report (OSR) with active orders as of 4/23/2026, the OSR indicated Resident 100 had an order of ampicillin IV for bacteremia.

The order was dated 4/18/2026.

During an observation on 4/21/2026 at 10:37 AM, at Resident 100's bedside, Resident 100's ampicillin IV bag was hanging on the IV pole (a tall stand that held the resident's IV fluids or medications) with Resident 100's health information (first and last name and room number) uncovered. Resident 100's ampicillin IV bag was unattended by facility staff and not connected to Resident 100.

During an observation on 4/23/2026 at 2:52 PM, at Resident 100's bedside, Resident 100's ampicillin IV bag was hanging on the IV pole with Resident 100's health information uncovered.

During an interview with Registered Nurse 1 (RN 1) on 4/23/2026 at 2:44 PM, RN 1 stated RN 1 did not cover Resident 100's health information on the ampicillin IV bag while hanging on the IV pole at Resident 100's bedside. RN 1 stated it risked exposing Resident 100's health information to unauthorized people. RN 1 stated visitors, housekeeping and maintenance personnel did not need to know Resident 100's health information nor the prescribed medication. RN 1 stated it was Resident 100's right to privacy by protecting Resident 100's health information. RN 1 stated it was important for everyone in the facility to protect the residents' rights to privacy.

During an interview with the Director of Nursing (DON) on 4/23/2026 at 3:43 PM, the DON stated the housekeeper and maintenance personnel had access to residents' rooms and did not need to know the residents' health information.

The DON stated everyone in the facility should protect the residents' health information as much as possible in accordance with Health Insurance Portability and Accountability Act (HIPPA- federal law that protected a resident's health information) laws.

During a review of the facility's Policy and Procedure (P&P) titled Confidentiality of Personal and Medical Records, revised on 12/19/2022, the P&P indicated the facility should honor the resident's right to secure and confidential personal and medical records.

The P&P indicated it included the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.

The P&P indicated the facility should safeguard the content of information including written documentation from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative.

The P&P further indicated resident's personal or medical information should not be left unattended or viewable by unauthorized persons.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During an interview on 4/24/2026 at 11:32 AM with Minimum Data Set Coordinator (MDS C), the MDS C stated it was important to develop a care plan with specific target interventions to solve the problem.

The MDS C stated there should have been an SBAR/Change of Condition (COC- documentation of significant, acute, or unexpected deviation from a patient's baseline) of Resident 42's scaling and stiffness of BLE following the application of the A&D ointment to Resident 42 on 3/18/2026.

During an interview on 4/24/2026, at 11:50 AM with Registered Nurse 4 (RN 4), RN 4 stated it was important to develop a care plan to address the resident's specific needs and to guide staff on what needed to be done. RN 4 stated there was no SBAR/COC created on 3/18/2026 related to Resident 42's complaint of scaling of skin and stiffness of BLE.

During a review of the facility's P&P titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated the facility should develop and implement a comprehensive resident-centered CP for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment.

The P&P indicated the comprehensive CP should be developed within seven days after the completion of the comprehensive MDS assessment.

The P&P indicated the CP should address the factors identified by the interdisciplinary team.

The P&P further indicated the CP should have specific interventions that reflected the resident's needs.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During a review of Resident 55's untitled CP dated 9/16/2021, the CP indicated Resident 55 had an indwelling catheter and was at high risk for catheter related infection or trauma.

The CP goals indicated Resident 55 would not show signs and symptoms of urinary infection and remain free from catheter-related trauma.

During a review of Resident 55's OSR dated 2/12/2026, the OSR indicated Resident 55 had an order for staff to apply catheter stabilization device to secure Resident 55's foley catheter was in place.

During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 had intact cognition.

The MDS indicated Resident 55 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity) with eating and oral hygiene, required partial/moderate assistance (helper did less than half the effort) with upper body dressing and personal hygiene and dependent (helper did all the effort) with toileting.

The MDS indicated Resident 55 had an indwelling catheter.

During a concurrent observation inside Resident 55's room and interview on 4/21/2026 at 9:01 am with Licensed Vocational Nurse 1 (LVN 1), Resident 55 was lying in bed with a foley catheter. LVN 1 stated Resident 55's Foley catheter was not connected to the catheter securement device. LVN 1 stated the foley catheter tubing should be secured to prevent getting pulled out during movement and cause trauma or injury to Resident 55.

During an interview on 4/23/2026 at 3:50 pm with the Director of Nursing (DON), the DON stated the foley catheter tubing should be secured on the resident's thigh to prevent from pulling and getting dislodged during bed mobility.

During a review of the facility's P&P titled, Catheter Care, revised on 12/23/2023, the P&P indicated, To ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

Ensure straps were snug but not tight.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/24/2026, the MDS indicated Resident 3 had severely impaired cognition (ability to understand and process information).

The MDS indicated Resident 3 was dependent (helper does all of the effort) from staff with eating, toileting, shower, upper and lower body dressing and putting on/taking off footwear.

During a review of Resident 3's triglyceride level laboratory result dated 2/25/2026, the laboratory result indicated Resident 3's triglyceride level was 226 milligrams per deciliter (mg/dl - unit of measurement).

The normal triglyceride level was below 150 mg/dl.

During a review of Resident 3's Nutritional Assessment (NA) dated 2/25/2026, the NA indicated the facility's Registered Dietitian (RD) recommended omega three oral capsule 1,200 milligrams (mg, unit of measurement) once daily for elevated triglycerides.

During a review of Resident 3's untitled Care Plan (CP) revised 4/8/2026, the CP indicated Resident 3 had actual/potential nutritional problems related to hyperlipidemia, anemia and dementia.

The CP intervention indicated for the RD to evaluate and make diet change recommendations as needed.

During an interview and record review on 4/22/2026 at 9:24 am with Registered Nurse 1 (RN 1), Resident 3's medical records (PointClickCare - PCC, a cloud-based software) were reviewed. RN 1 stated Resident 3 received RD recommendation of omega three oral capsule 1,200 mg for elevated triglycerides. RN 1 stated, it was RN 1's responsibility to carry out the RD recommendation. RN 1 stated RN 1 did not follow up with Resident 3's primary physician. RN 1 stated the purpose of RD recommendation was to check the nutritional needs of the residents. RN 1 stated Resident 3's triglyceride level was elevated at 226 mg/dl.

During a concurrent interview and record review of the Medical Nutritional Therapy Assessment Recommendations Form (MNTARF) on 4/22/2026 at 9:26 am, RN 1 stated, RN 1 received the RD recommendation for Resident 3 on 2/25/2026. RN 1 stated Resident 3 had a recommendation to start omega three oral capsule 1,200 mg once daily for elevated triglycerides.

During an interview on 4/22/2026 at 9:28 am, with the Director of Nursing (DON), the DON stated there was no specific timeframe to carry out or to act upon the RD recommendations.

The DON stated the RD recommendations should be acted upon as soon as possible.

The DON stated, the purpose of RD recommendation was to ensure the resident's nutritional needs were met as recommended.

The DON stated if the RD recommendation was not acted upon, Resident 3's needs and goals would not be met as recommended.

During a review of the facility's P&P titled, Nutritional and Dietary Supplements, dated 12/19/2022, the P&P indicated, It is the policy of the facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being.

Resident's nutritional status will be accurately and consistently assessed upon admission and on an as needed basis to identify a resident at nutritional risk and address risk factors for impaired nutritional status.

Supplements may be recommended by a Registered Dietitian and implemented post physician orders.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During an interview on 4/24/2026, at 9:14 am, with the DON, the DON stated

aspiration.

During a review of the facility's undated Policy and Procedure (P&P) titled, Gastrostomy Site Care, dated 12/19/2022 the P&P indicated It is the policy of the facility to perform gastrostomy site care as ordered and per current standards of practice.

Using normal saline, gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During a review of Resident 22's untitled Care Plan (CP) dated 12/22/2025, the CP indicated Resident 22 was on oxygen therapy related to shortness of breath.

The CP goals indicated for Resident 22 not to have signs and symptoms of poor oxygen absorption.

During a review of Resident 22's Order Summary Report (OSR) dated 12/22/2025, the OSR indicated Resident 22 had an order for oxygen via nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at two liters per minute (l/min) and an order for breathing treatment of albuterol solution, three milliliters (ml- unit of measurement) to be administered via nebulizer every six hours for shortness of breath or wheezing (abnormal breath sound) dated 12/23/2025.

During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool) dated 12/26/2025, the MDS indicated Resident 22 had moderately impaired cognition (ability to understand and process information).

The MDS indicated Resident 22 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper body dressing and personal hygiene and partial/moderate assistance (helper did less than half the effort) with toileting, shower and lower body dressing.

During a concurrent observation of Resident 22's room and interview on 4/21/2026 at 9:18 am with Licensed Vocational Nurse 3 (LVN 3), Resident 22 was not in the room. Resident 22's nebulizer mask was left hanging on the bedrail and the oxygen tubing was left on the bed. LVN 3 stated that the nebulizer mask and oxygen tubing should be stored inside the transparent bag intended for storage of respiratory supplies when not in use to prevent contamination and spread of infection.

During an interview on 4/23/2026 at 3:52 pm with the Director of Nursing (DON), the DON stated all respiratory supplies should be placed inside the clear, transparent bag when not in use for infection control.

During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised on 5/20/2024, the P&P indicated, Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment.

Other infection control measures include to keep delivery services covered in plastic bag when not in use.

During a concurrent observation and interview with the Dietary Supervisor (DS) on 4/21/2026 at 8:26 AM, in the kitchen bread storage area, there was one open loaf of wheat bread beyond its use-by-date of 4/20/2026.

The DS stated the kitchen staff should discard the bread because it was beyond the use-by-date of 4/20/2026. b.

During a concurrent observation and interview with the DS on 4/21/2026 at 8:40 AM, in the kitchen dry storage area, there was one open plastic container of baking soda beyond its use-by-date of 4/15/2026.

The DS stated the kitchen staff should discard the baking soda because it was beyond the use-by-date of 4/15/2026. c.

During a concurrent observation and interview with the DS on 4/21/2026 at 8:47 AM, in the kitchen walk-in refrigerator, there was one open pack of tortilla beyond its use-by-date of 4/19/2026.

The DS stated the kitchen staff should discard the pack of tortilla because it was beyond the use-by-date of 4/19/2026. d.

During a concurrent observation and interview with the DS on 4/21/2026 at 8:52 AM, in the kitchen walk-in refrigerator, there was one tray of grilled cheese sandwiches and pizzas beyond its use-by-date of 4/20/2026.

The DS stated the kitchen staff should discard the tray of grilled cheese sandwiches and pizzas because it was beyond the use-by-date of 4/20/2026.

During an interview with the Infection Preventionist Nurse (IPN) on 4/23/2026 at 9:38 AM, the IPN stated staff should throw away the food beyond the use-by-date because it could cause food-borne illnesses.

The IPN stated it was not acceptable to have food for the residents beyond the used-by-date.

The IPN stated it was part of infection control to discard food beyond the use-by-date.

During an interview with the DS on 4/23/2026 at 10:39 AM, the DS stated it would affect the quality of the food when food was beyond the used-by-date.

The DS stated the bread would lose moisture after the use-by date.

The DS stated it was not acceptable to provide food beyond the used-by-date because it could cause nausea and vomiting.

The DS stated it was part of infection control and quality of care to provide the best quality of food to the residents.

During a review of the facility's Policy and Procedure (P&P) titled, Date Marking for Food Safety, revised 12/19/2022, the P&P indicated staff should clearly marked the food to indicate the date or day by which the food shall be consumed or discarded.

During a review of the facility's P&P titled, Food storage, revised 8/29/2023, the P&P indicated staff should discard any outdated food products.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During an interview with the Director of Nursing (DON) on 4/23/2026 at 3:43 PM, the DON stated it was not acceptable to document the ampicillin 12 PM dose at 6:58 PM on 4/21/2026.

The DON stated it was the standard of practice to document medication administration timely at the time of service.

During a review of the facility's Policy and Procedure (P&P) titled Documentation in Medical Record, dated 12/19/2022, the P&P indicated the licensed staff should document all assessments, observations, and services provided in the resident's medical record at the time of service, but no later than the shift.

The P&P indicated documentation should be timely.

During a review of the facility's P&P titled Medication Administration, dated 12/19/2022, the P&P indicated the licensed nurse should administer medication within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

The P&P further indicated the licensed nurse should sign the medication administration record after administrating the medication.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706

During an interview on 4/24/2026 at 9:07 am with the facility's Director of Nursing (DON), the DON stated caregivers, visitors and staff needed to wear gown, gloves and masks before providing direct care to residents on EBP.

During a review of the facility's P&P titled, EBP, revised on 3/10/2025, the P&P indicated, It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP are indicated for residents with any of the following: etc. indwelling medical devices (e.g., feeding tube) even if the resident is not known to be infected.

Implementation of Enhanced Barrier Precautions: Make gowns and gloves available prior to performing task.

Provide education to residents and visitors.

High-contact resident care activities include dressing, bathing/showering etc.providing hygiene.

Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

056466 04/24/2026

Sierra View Care Center 14318 Ohio Street Baldwin Park, CA 91706