Park Avenue Healthcare & Wellness Center

F-F842

Findings:

a. During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1

on 5/25/2022 with diagnoses that included immunodeficiency (decreased ability of the body to fight infections and other diseases), and personal history of COVID -19 (Coronavirus -19, highly contagious virus that can affect lungs and airways and spreads form person to person).

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/9/2024, the MDS indicated Resident 1's cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 1/RP 1 was offered and declined the flu vaccine (on 10/20/2023). The MDS indicated Resident 1 did not receive the flu vaccine while at the facility.

During a review of Resident 1's eINTERACT/Change in Condition Evaluation (CIC, a change in the resident's health or functioning that requires further assessment and intervention) form, dated 12/27/2024, timed at 3:25 pm, the CIC indicated Resident 1 was noted with increased fatigue (extreme tiredness) and slept more than usual.

During a review of Resident 1's Progress Notes (PN), dated 12/27/2024, timed at 10:50 pm, the PN indicated Resident 1 was being monitored for increased fatigue and fever.

During a review of Resident 1's Order Summary Report (OSR), dated 12/28/2024, the OSR indicated for Resident 1 to be transferred to General Acute Care Hospital (GACH) 1 for evaluation and treatment.

During a review of Resident 1's CIC, dated 12/28/2024, timed at 2:54 pm, the CIC indicated Resident 1 had episodes of vomiting and Resident 1's oxygen saturation [O2 sats, the percentage (%) of hemoglobin (a red protein responsible for transporting oxygen) in the blood] dropped (% was not indicated). The CIC indicated Resident 1 was put on 02 via nasal cannula (NC, a small plastic tube which fits into the person's nostrils for providing supplemental oxygen). The CIC indicated Resident 1 was sent to GACH 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a review of Resident 1's GACH 1 H&P, dated 12/28/2024, timed at 6:20 am, the H&P indicated Resident 1 was brought to GACH 1's Emergency Department (ED) for fever and hypoxia (a condition where Level of Harm - Immediate the body's tissues do not receive enough oxygen). The H&P indicated Resident 1 was febrile (also known as jeopardy to resident health or fever), tachycardic [heart rate faster that 100 beats per minute (BPM)], and sepsis. Resident 1 received safety intravenous [IV, a soft, flexible tube placed inside a vein (a blood vessel that carries blood to the heart from

the tissues and organs in the body) to administer fluids and medication directly to the bloodstream] fluids and Residents Affected - Some antibiotic (medicine used to treat bacterial infections) per sepsis protocol (a set of guidelines followed by healthcare providers to treat sepsis). The H&P indicated, Resident 1's laboratory results (findings from a medical test) indicated, Influenza A (one of three types of viruses that cause the illness called influenza was detected).

During a telephone interview on 1/15/2025 at 10:32 am with RP 1, RP 1 stated RP 1 would not decline the flu vaccine for Resident 1.

b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 4/16/2024 with diagnoses that included unspecified immunodeficiency, and type 2 diabetes mellitus [DM2, a chronic (long standing) disease that occurs when the body does not produce enough insulin (a hormone that regulates the amount of glucose/sugar in the blood)].

During a review of Resident 2's H&P, dated 12/20/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.

During a review of Resident 2's CIC, dated 12/26/2024, timed at 6:34 pm, the CIC indicated Resident 2 had

a O2 Sat of 79 % (normal level of oxygen saturation level (measure of how much oxygen is traveling through your body in your red blood cells) is between 95% and 100%) and a fever of 102.1 degrees Fahrenheit [ F, unit of temperature (a normal body temperature is generally considered to be 98.6 F)]. The CIC indicated Resident 2's primary care provider recommended for Resident 2 to be transferred to GACH 2 via emergency services by calling 911 (a phone number used to contact emergency services).

During a review of Resident 2's GACH 2 H&P, dated 12/27/2024, timed at 3:06 pm, the H&P indicated Resident 2 tested positive for Influenza A (contagious viral infection that can have life-threatening complications if left untreated) and had a fever secondary to the flu and PNA.

During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had moderate impaired cognition. The MDS indicated Resident 2/RP 2 was offered and declined the flu vaccine (on 10/20/2023).

c. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses that included DM2, immunodeficiency, personal history of COVID - 19, and PNA.

During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 3 had moderate impaired cognition. The MDS indicated, Resident 3 received the flu vaccine in the facility on 11/29/2023.

During a review of Resident 3's CIC, dated 12/30/2024, timed at 9:03 am, the CIC indicated Resident 3 was noted with increased weakness and poor oral (PO, by mouth/orally) intake. The CIC indicated Resident 3's physician ordered to send Resident 3 to GACH 3 for further evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a review of Resident 3's OSR, dated 12/30/2024, the OSR indicated to transfer Resident 3 to GACH 3 for further evaluation. Level of Harm - Immediate jeopardy to resident health or During a review of Resident 3's GACH 3 H&P, dated 12/31/2024, timed at 12 pm, the H&P indicated safety Resident 3 presented to GACH 3's ED with failure to thrive (FTF, a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity). The Residents Affected - Some H&P indicated Resident 1 was currently on Levofloxacin (medication used to treat infections) 250 milligrams, (mg, unit of measurement) IV, every 24 (Q 24) hours.

During a review of Resident 3's GACH 3 Discharge Summary (DS) dated 1/5/2025, timed at 10:17 am, the DS indicated Resident 3 was admitted with multiple diagnoses including, Influenza A and PNA. The DS indicated the hospital problem list included hypoxia (absence of enough oxygen in the tissues to sustain body functions) likely due to PNA. The DS indicated to continue droplet (mucus and/or saliva spray from coughing, sneezing, or talking) isolation (separation of residents who have an infection from residents who do not have infections) and starting Tamiflu (medication used to treat the flu).

During a review of Resident 3's PN, dated 1/5/2025, timed at 4:55 pm, the PN indicated Resident 3 was readmitted from GACH 3 with Influenza A and was currently on droplet precautions (Droplet precautions are necessary when a patient infected with a pathogen, such as influenza, is within three to six feet of the patient).

d. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses that included atherosclerotic heart disease (a type of heart disease that occurs when plaque builds up inside the arteries) of native coronary artery (major blood vessels in the body supply blood to the heart) without angina pectoris (chest pain), and immunodeficiency.

During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated Resident 4 had moderately impaired cognition. The MDS indicated Resident 4/RP 4 was offered the flu vaccine and declined (on 11/8/2023).

During a review of Resident 4's CIC, dated 12/25/2024, at 9:21 pm, the CIC indicated Resident 4 had a fever of 102.3 F, O2 sats of 83 % on room air (no supplemental oxygen), and was tachycardic (fast/increased heart rate) at 117 beats per minute, (BPM, a normal resting heartbeat/heartrate should be between 60 to 100 BPM). The CIC indicated Resident 4's attending physician recommended to transfer Resident 4 to GACH 1 via emergency services by calling 911 for further evaluation.

During a review of Resident 4's GACH 1 Emergency Department Physician Note (EDPN), dated 12/26/2024, timed at 12:18 am, the EDPN indicated Resident 4 presented to the ED with shortness of breath (the feeling of not being able to breathe deeply enough or getting enough air into your lungs), productive cough [a type of cough that produces mucus (phlegm or sputum)], and fevers of 103 F for two days. The EDPN indicated Resident 4 needed to be admitted to GACH 1 for treatment of Influenza A, PNA, and sepsis.

e. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE REDACTED] with diagnoses that included unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning), and personal history of COVID-19.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a review of Resident 5's MDS, dated [DATE REDACTED], the MDS indicated Resident 5 had moderate impaired cognition. The MDS indicated Resident 5 was offered and declined the flu vaccine and Resident 5 did not Level of Harm - Immediate receive the flu vaccine in the facility. jeopardy to resident health or safety During a review of Resident 5's CIC, dated 1/6/2025, timed at 1:58 pm, the CIC indicated Resident 5 was positive for Influenza A and had a non-productive cough (dry cough). The CIC indicated Resident 5's Residents Affected - Some physician was notified, and the physician ordered Tamiflu, 75 mg, twice a day (BID) for five days.

f. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 9/22/2023 with diagnoses that included unspecified respiratory failure (a serious condition that makes it difficult to breathe), unspecified dementia, and DM2.

During a review of Resident 6's H&P, dated 9/27/2024, the H&P indicated Resident 6 did not have the capacity to understand and make decisions due to a diagnosis of dementia.

During a review of Resident 6's MDS, dated [DATE REDACTED], the MDS indicated Resident 6 had severe impaired cognition. The MDS indicated Resident 6 was offered and declined the flu vaccine.

During a review of Resident 6's CIC dated 1/5/2025, timed at 11:09 am, the CIC indicated Resident 6 could not swallow, had a productive (wet- full of mucus or phlegm) cough, and Resident 6's O2 Sat was at 87 % when on room air. The CIC indicated Resident 6 was transferred to the ED for further evaluation.

During a review of Resident 6's GACH 1 H&P, dated 1/5/2025, the H&P indicated Resident 6 was exposed to Influenza at the facility, and presented with upper respiratory symptoms, short of breath, acute (sudden) respiratory failure, and tested positive for Influenza A. The H&P indicated a chest X-ray (imaging study that takes pictures of bones and soft tissues) showed pulmonary infiltrate (PNA).

During a review of Resident 6's CDII dated 1/9/2025, the CDII indicated Resident 6 verbally declined the flu vaccine due to not feeling well. The CDII indicated IP 1signed Resident 6's IP form.

During a review of Resident 6's PN, dated 1/14/2025, timed at 10:51 pm, the PN indicated IP 1, spoke with resident regarding influenza vaccine. Resident is self-responsible and verbally declined . The PN indicated IP 1 was the author of the note.

During a concurrent interview and record review on 1/15/2025 at 11:39 am, with IP 1, Resident 6's MDS, dated [DATE REDACTED] was reviewed, the MDS indicated Resident 6 had severe impaired cognition. IP 1 stated Resident 6 declined the flu vaccine. IP 1 stated, It was not safe to offer Resident 6 the flu vaccine because Resident 6 could not understand the risks and benefits of the flu vaccine.

g. During a review of Resident 7's AR, the AR indicated, Resident 7 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including DM2 without complications, immunodeficiency, and heart failure (a lifelong condition in which the heart muscle could not pump enough blood to meet the body's needs for blood and oxygen).

During a review of Resident 7's H&P, dated 12/17/2024, the H&P indicated, Resident 7 could make needs known but could not make medical decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a review of Resident 7's MDS, dated [DATE REDACTED], the MDS indicated Resident 7's cognition was moderately impaired. The MDS indicated Resident 7 was offered and declined the flu vaccine and Resident Level of Harm - Immediate 7 did not receive the flu vaccine at the facility. jeopardy to resident health or safety During a review of Resident 7's CIC, dated 1/11/2025, timed at 7:11 am, the CIC indicated a CNA (unidentified) reported Resident 7 complained Resident 7 could not breath. The CIC indicated Resident 7's Residents Affected - Some O2 sats were at 78 % while Resident 7 was on 2 liters (L, unit of volume) of O2 via NC. The CIC indicated Resident 7's oxygen delivery rate was increased to 4 L.

During a review of Resident 7's OSR, dated 1/11/2025, the OSR indicated to send Resident 7 to GACH 1 due to altered level of consciousness (ALOC, which is a state where someone is less awake, alert, or aware of their surroundings) and O2 desaturations (a drop in blood oxygen levels).

During a review of Resident 7's GACH 1 H&P, dated 1/11/2025, timed at 6:57 pm, and signed on 1/12/2025 at 12:57 am, the H&P indicated Resident 7 presented to ED with reports of acute (sudden and severe) onset shortness of breath, hypoxia, and cough. The H&P indicated, Resident 7 was afebrile, hypoxic (low levels of oxygen in the body's tissues), and tachypneic (rapid, shallow breathing). The H&P indicated, Resident 7's workup (process of obtaining all necessary data for diagnosing and treating a patient) revealed pneumonia and Resident 7 was positive for influenza. The H&P's assessment/plan indicated, Resident 7 was in septic shock (severe drop in blood pressure caused by an infection) and the plan was to admit Resident 7 to the ICU (Intensive Care Unit - a department of a hospital in which patients who are?dangerously?ill are kept under constant observation) and continue administration of IV antibiotics and bronchodilators (medication used to widen the airways to make breathing easier).

During a review of Resident 7's GACH 1 Critical Care/Pulmonologist (doctor who specializes in lung conditions) Consultation Notes (CN), dated 1/11/2025, signed at 12:58 pm, the CN indicated, Resident 7 was

in severe sepsis and acute hypoxic with respiratory failure 2/2 (secondary to) pneumonia. The CN indicated Resident 7 was ill-appearing, frail, moderate distress, awake but not alert on HFNC (HiFlow Nasal Cannula -

a type of non-invasive device for providing supplemental oxygen) and to monitor closely for intubation (a procedure involving a tube placed inside your trachea, also called the windpipe, through the mouth or nose and attached to a machine that helps you breathe). The CN indicated, to continue empiric (medical treatment initiated without definitive knowledge of the underlying cause or pathogen) antibiotics and start Tamiflu.

During a review of Resident 7's GACH 1 Infectious Disease (doctor who specializes in the diagnosis and treatment of illnesses and infections) CN, dated 1/12/2025, timed at 1:41 pm, the CN indicated, Resident 7 was in septic shock, likely secondary to Influenza A and pneumonia likely secondary to Influenza A.

During a concurrent interview and record review of Resident 7's CDII form on 1/14/2025 at 5:08 pm, with IP 1, IP 1 stated Resident 7's RP consented for Resident 7 to receive the flu vaccine on 12/18/2024. IP 1 stated

the flu vaccine was not administered to Resident 7. IP 1 stated Resident 7 should have been offered the flu vaccine upon admission on 12/16/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a concurrent interview and record review on 1/14/2025 at 5:08 pm, with IP 1, the facility's line list (a table that summarizes key information about each case during an outbreak (OB, two or more linked cases of Level of Harm - Immediate the same illness) for the influenza was reviewed. The line listing was incomplete with missing information for jeopardy to resident health or Residents 1, 2, 3, 4, 5, 6, and 7. IP 1 stated the flu season started on 10/1/2024 until 3/31/2025. IP 1 stated safety staff (licensed nurses) began offering the flu vaccine as early as late September and began administering the flu vaccine to residents as early as 10/1/2024. IP 1 stated (in general) the flu vaccine should be administered Residents Affected - Some within three days, after a resident or RP consented to receive the flu vaccine. IP 1 stated it was important to offer the flu vaccine at the beginning of each flu season to prevent residents from getting sick from the flu, or for the symptoms to be minimized. IP 1 stated the IPs (IPs 1 and 2) were not following the process and were not appropriately tracking residents' flu vaccine status because the facility was not organized. IP 1 stated IP 1 did not have an answer to why the facility was not following the facility's process for vaccinating residents. IP 1 and IP 2 stated the flu OB line list provided was not up to date (incomplete). IP 1 stated all residents were more susceptible to catching the flu because the IPs did not know what residents were vaccinated and what residents were not vaccinated.

During an interview on 1/15/2025 at 4:21 pm, with the DON, the DON stated the process for obtaining flu vaccine consents was for admitting nurses to offer and obtain the consent or declination form from either the resident or their RPs. The DON stated all licensed nurses were responsible for conducting flu vaccine status screening upon a residents' admission. The DON stated, It was important to screen residents to protect them from the flu and prevent the development of an infection. The DON stated the IPs were supposed to follow up on any newly admitted residents and screen all residents in August to offer and obtain consents for the flu season that started on 10/1/2024. The DON stated a flu vaccine tracking system was important because it allowed for the facility to keep track of all residents' flu vaccination status. The DON stated when there was no tracking system or log in place, residents who were medically eligible to receive the flu vaccine would not be offered the vaccine because of the facility's disorganization [lack of tracking].

During a review of the facility's undated Centers for Disease Control and Prevention Vaccine Information Statements (CDC VIS), the CDC VIS indicated people [AGE] years and older, and people with certain health conditions such as heart disease, cancer, diabetes, or a weakened immune system were at greater risk of flu complications. The CDC VIS indicated flu could cause fever and chills, sore throat, muscle aches, fatigue, cough, headache, and runny or stuffy nose. The CDC VIS indicated flu vaccine prevented millions of illnesses and flu-related visits to the doctor each year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During a review of the facility's P&P titled, Influenza Prevention and Control revised 9/10/2020, the P&P indicated to prevent and control the spread of influenza in the facility, the facility would follow infection Level of Harm - Immediate prevention and control policies and procedures to minimize the risk of residents acquiring, transmitting or jeopardy to resident health or experiencing complications from influenza. The P&P indicated the CDC considered the flu season to be safety between October 1st and March 31st. The P&P indicated residents were to be offered the influenza immunization every year during flu season, unless medically contraindicated, or the resident had already Residents Affected - Some been immunized during the current flu season. The P&P indicated the resident's medical record would include documentation that indicated, at a minimum, the resident or the resident's representative was provided education regarding the risk and benefits and potential side effects of the influenza vaccination and whether the resident received the influenza vaccine, could not receive the vaccine due to a medical contraindication or refused the vaccine. P&P indicated the vaccine type, dose, route, and nurse administering the vaccine would be documented on the medication administration record. The P&P indicated

the vaccine lot number would be recorded on the immunization log.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 555852

F-F883

Findings:

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 1a. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses that included atherosclerotic heart disease (a type of heart disease that occurs when plaque Level of Harm - Minimal harm or builds up inside the arteries) of native coronary artery (major blood vessels in the body supply blood to the potential for actual harm heart) without angina pectoris (chest pain), and immunodeficiency.

Residents Affected - Some During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 11/22/2024,

the MDS indicated Resident 4 had moderately impaired cognition (ability to think, reason, and understand).

The MDS indicated Resident 4/RP 4 was offered the flu vaccine and declined (on 11/8/2023).

During a review of Resident 4's eINTERACT/Change in Condition notification (CIC- a change in the resident's health or functioning that requires further assessment and intervention) dated 12/25/2024 at 9:21 pm, the CIC indicated Resident 4 had a fever of 102.3 degrees Fahrenheit [ F, unit of temperature (a normal body temperature is generally considered to be 98.6 F)], oxygen saturation [O2 sats, the percentage (%) of hemoglobin (a red protein responsible for transporting oxygen) in the blood]of 83% (normal level of oxygen saturation level is between 95% and 100%)on room air (no supplemental oxygen) and was tachycardic (fast/increased heart rate) at 117 beats per minute, (BPM, a normal resting heartbeat/heartrate should be between 60 to 100 BPM) The CIC indicated Resident 4's attending physician recommended to transfer Resident 4 to GACH 1 via 9-1-1 (phone number used to contact emergency services in the event of a medical emergency) for further evaluation.

During a review of Resident 4's GACH 1 Emergency Department Physician Note (EDPN), dated 12/26/2024, timed at 12:18 am, the EDPN indicated Resident 4 presented to the ED with shortness of breath (the feeling of not being able to breathe deeply enough or getting enough air into your lungs), productive cough [a type of cough that produces mucus (phlegm or sputum)], and fevers of 103 F for two days. The EDPN indicated Resident 4 needed to be admitted to GACH 1 for treatment of Influenza A, PNA, and sepsis.

During a review of Resident 4's CDII dated 1/13/2025, the CDII indicated IP 1 spoke to Resident 4's RP via telephone, who verbally declined the flu vaccine due to fear of side effects.

During a concurrent interview and record review on 1/14/2025 at 5:08 pm. Resident 4's MDS, dated [DATE REDACTED] was reviewed, the MDS indicated Resident 4/RP 4 was offered the flu vaccine and declined. IP 1 stated the flu vaccine was last offered to Resident 4/RP 4 on 11/8/2023.

During a concurrent interview and record review on 1/15/2025 at 11:39 am, with IP 1, Residents 4's CDII was reviewed. IP 1 stated the process for obtaining flu vaccine consent from a RP was to verify the name of the RP called, provide a verbal vaccine information statement (VIS- information sheet that explains the benefits and risks of a vaccine) including the risks and benefits, indicate on the CDII if the RP consents or declines, and cosign the CDII with a licensed nurse witness. IP 1 stated the cosigner should be present during the call to ensure accuracy. IP 1 stated on 1/13/2025, IP 1 documented IP 1 spoke to RP 4 regarding the flu vaccine for Resident 4. IP 1 stated IP 1 documented and signed RP 4 declined the flu vaccine for Resident 4. IP 1 stated IP 1 did not speak to RP 4 but left a voicemail.

During a telephone interview on 1/15/2025 at 4:51 pm, with RP 4, RP 4 stated facility staff did not call RP 4 to offer the flu vaccine for Resident 4 (for the current flu season). RP 4 stated RP 4 would not decline the flu vaccine for Resident 4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 1b. During a review of Resident 9's AR, the AR indicated the facility originally admitted Resident 9 on 5/11/2022, and readmitted Resident 9 on 8/5/2022, with diagnoses that included DM2, unspecified heart Level of Harm - Minimal harm or failure, and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or potential for actual harm nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA- disruption of blood flow to the brain due to problematic vessels that cause lack of Residents Affected - Some blood supply and oxygen to the brain) affecting the left non-dominant side.

During a review of Resident 9's History and Physical (H&P) dated 4/22/2024, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.

During a review of Resident 9's MDS dated [DATE REDACTED], the MDS indicated Resident 9 had moderately impaired cognition. The MDS indicated Resident 4 was offered and declined the flu vaccine.

During a review of Resident 9's CDII dated 1/13/2025, the CDII indicated IP 1 spoke to Resident 9's RP via telephone, who verbally declined the flu vaccine indicating Resident 9's RP, Don't want at this time.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, Residents 9's CDII was reviewed. IP 1 stated on 1/13/2025, IP 1 documented IP 1 spoke to Resident 9's RP regarding the flu vaccine for Resident 9. IP 1 stated IP 1 documented and signed Resident 9's RP declined the flu vaccine for Resident 9. IP 1 stated IP 1 did not speak to Resident 9's RP but left a voicemail. IP 1 stated IP 1 documented IP 1 spoke to Resident 9's RP because IP 1, Was stressed.

1c. During a review of Resident 1's AR, the AR indicated the facility admitted Resident 1 on 5/25/2022 with diagnoses that included immunodeficiency (decreased ability of the body to fight infections and other diseases), and personal history of COVID -19 (Coronavirus -19, highly contagious virus that can affect lungs and airways and spreads form person to person).

During a review of Resident 1's MDS, dated [DATE REDACTED], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1/RP 1 was offered and declined the flu vaccine (on 10/20/2023). The MDS indicated Resident 1 did not receive the flu vaccine while at the facility.

During a review of Resident 1's CIC form, dated 12/27/2024, timed at 3:25 pm, the CIC indicated Resident 1 was noted with increased fatigue (extreme tiredness) and slept more than usual.

During a review of Resident 1's Progress Notes (PN), dated 12/27/2024, timed at 10:50 pm, the PN indicated Resident 1 was being monitored for increased fatigue and fever.

During a review of Resident 1's Order Summary Report (OSR), dated 12/28/2024, the OSR indicated for Resident 1 to be transferred to General Acute Care Hospital (GACH) 1 for evaluation and treatment.

During a review of Resident 1's CIC, dated 12/28/2024, timed at 2:54 pm, the CIC indicated Resident 1 had episodes of vomiting and Resident 1's oxygen saturation [O2 sats, the percentage (%) of hemoglobin (a red protein responsible for transporting oxygen) in the blood] dropped (% was not indicated). The CIC indicated Resident 1 was put on 02 via nasal cannula (NC, a small plastic tube which fits into the person's nostrils for providing supplemental oxygen). The CIC indicated Resident 1 was sent to GACH 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of Resident 1's GACH 1 H&P, dated 12/28/2024, timed at 6:20 am, the H&P indicated Resident 1 was brought to GACH 1's Emergency Department (ED) for fever and hypoxia (a condition where Level of Harm - Minimal harm or the body's tissues do not receive enough oxygen). The H&P indicated Resident 1 was febrile (also known as potential for actual harm fever), tachycardic [heart rate faster that 100 beats per minute (BPM)], and sepsis. Resident 1 received intravenous [IV, a soft, flexible tube placed inside a vein (a blood vessel that carries blood to the heart from Residents Affected - Some the tissues and organs in the body) to administer fluids and medication directly to the bloodstream] fluids and antibiotic (medicine used to treat bacterial infections) per sepsis protocol (a set of guidelines followed by healthcare providers to treat sepsis). The H&P indicated, Resident 1's laboratory results (findings from a medical test) indicated, Influenza A (one of three types of viruses that cause the illness called influenza was detected).

During a review of Resident 1's CDII, dated 1/13/2025, the CDII indicated the facility spoke with RP 1 by telephone who declined the flu vaccine for personal reasons (fear of side effects).

During a concurrent interview and record review on 1/14/2025 at 5:08 pm, Resident 1's MDS, dated [DATE REDACTED] was reviewed with IP 1, the MDS indicated Resident 1/RP 1 was offered the flu vaccine and declined. IP 1 stated the flu vaccine was last offered to RP 1 on 10/20/2023.

During a telephone interview on 1/15/2025 at 10:32 am with RP 1, RP 1 stated no one from the facility, called RP 1 to offer the flu vaccine for Resident 1 (during the current flu season). RP 1 stated RP 1 would not decline the flu vaccine for Resident 1.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, Residents 1's CDII was reviewed. IP 1 stated IP 1 did not call RP 1 on 1/13/2025. IP 1 stated RP 1 did not verbally decline the flu vaccine for Resident 1. IP 1 stated IP 1 documented and signed RP 1 decline the flu vaccine for Resident 1 because IP 1 was Stressed out, and trying to get through the resident list As fast as possible to schedule residents for an upcoming vaccine clinic.

1d. During a review of Resident 10's AR, the AR indicated the facility admitted Resident 10 on 2/16/2023 with diagnoses that included chronic sinusitis (long-term sinus infection that involves inflammation of the sinuses or nasal passages), hemiplegia (paralysis of one side of the body) affecting the right dominant side, and personal history of COVID-19.

During a review of Resident 10's H&P dated 2/20/2024, the H&P indicated Resident 10 had a history of chronic respiratory failure (serious condition that makes it breathe on one's own). The H&P indicated Resident 10 was non-verbal (unable to speak) and not following commands.

During a review of Resident 10's MDS dated [DATE REDACTED], the MDS indicated Resident 10 had severely impaired cognition. The MDS indicated Resident 10 was offered and declined the flu vaccine.

During a review of Resident 10's CDII dated 1/13/2025, the CDII indicated IP 1 spoke to Resident 10's RP via telephone, who verbally declined the flu vaccine due to the fear of side effects.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, Residents 10's CDII was reviewed. IP 1 stated on 1/13/2025, IP 1 most likely did not speak to Resident 10's RP to get a declination for flu vaccine for Resident 10. IP 1 stated IP 1 documented that IP 1 spoke to Resident 10's RP because IP 1, Was stressed out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 1e. During a review of Resident 12's AR, the AR indicated the facility originally admitted Resident 12 on 4/3/2023, and readmitted Resident 12 on 12/23/2023, with diagnoses that included acute kidney injury (AKI- Level of Harm - Minimal harm or when the kidneys suddenly stop working due to complication of another serious illness), chronic obstructive potential for actual harm pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), and hypertensive heart disease without heart failure. Residents Affected - Some

During a review of Resident 12's H&P dated 10/24/2024, the H&P indicated Resident 12 did not have the capacity to understand and make decisions.

During a review of Resident 12's MDS dated [DATE REDACTED], the MDS indicated Resident 12 had moderately impaired cognition. The MDS indicated Resident 12 received the flu vaccine in the facility for this year's influenza season (2024-2025). The MDS indicated Resident 12 received the flu vaccine on 10/20/2023.

During a review of Resident 12's CDII dated 1/14/2025, the CDII indicated IP 1 spoke to Resident 12's RP via telephone, who verbally declined the flu vaccine due to not wanting at this time.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, Residents 12's CDII was reviewed. IP 1 stated on 1/14/2025, IP 1 documented and signed that Resident 12's RP declined the flu vaccine, and that IP 1 spoke to Resident 12's RP. IP 1 stated IP 1 only left a voicemail for Resident 12's RP. IP 1 stated IP 1 documented that IP 1 spoke to Resident 12's RP because IP 1, Was stressed.

1f. During a review of Resident 11's AR, the AR indicated the facility admitted Resident 11 on 6/18/2023 with diagnoses that included PNA due to COVID-19, chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should), and metabolic encephalopathy (disease of the brain that alters brain function or structure due to chemical imbalance in the blood).

During a review of Resident 11's H&P dated 6/27/2024, the H&P indicated Resident 11 did not have the capacity to make decisions.

During a review of Resident 11's MDS dated [DATE REDACTED], the MDS indicated Resident 11 had severely impaired cognition. The MDS indicated Resident 11 was offered and declined the flu vaccine.

During a review of Resident 11's CDII, dated 1/14/2025, the CDII indicated IP 1 spoke to Resident 11's RP via telephone who verbally declined the flu vaccine due to fear of side effects.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, Residents 11's CDII was reviewed. IP 1 stated on 1/14/2025, IP 1 documented and signed that Resident 11's RP declined the flu vaccine, and that IP 1 spoke to Resident 11's RP. IP 1 stated IP 1 only left a voicemail for Resident 11's RP. IP 1 stated IP 1 documented that IP 1 spoke to Resident 11's RP because IP 1, Was stressed.

1g. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 4/16/2024 with diagnoses that included unspecified immunodeficiency, and type 2 diabetes mellitus [DM2, a chronic (long standing) disease that occurs when the body does not produce enough insulin (a hormone that regulates the amount of glucose/sugar in the blood)].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of Resident 2's H&P, dated 12/20/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's CIC, dated 12/26/2024, timed at 6:34 pm, the CIC indicated Resident 2 had

a O2 sats of 79 % and a fever of 102.1 F. The CIC indicated Resident 2's primary care provider Residents Affected - Some recommended for Resident 2 to be transferred to GACH 2 via emergency services by calling 911.

During a review of Resident 2's GACH 2 H&P, dated 12/27/2024, timed at 3:06 pm, the H&P indicated Resident 2 tested positive for Influenza A and had a fever secondary to the flu and PNA.

During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had moderate impaired cognition. The MDS indicated Resident 2/RP 2 was offered and declined the flu vaccine (on 10/20/2023).

During a review of Resident 2's CDII dated 1/13/2025, the CDII indicated IP 1 spoke to Resident 2's RP (RP 2) via telephone who verbally declined the flu vaccine due to fear of side effects.

During a concurrent interview and record review on 1/14/2025 at 5:08 pm, Resident 2's MDS, dated [DATE REDACTED] was reviewed with IP 1, the MDS indicated Resident 2/RP 2 was offered the flu vaccine and declined. IP 1 stated the flu vaccine was last offered to RP 2 on 10/20/2023.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, Residents 2's CDII was reviewed. IP 1 stated IP 1 did not speak to RP 2 on 1/13/2025 to offer the flu vaccine. IP 1 stated IP 1 left a voicemail for RP 2, but documented and signed on Resident 2's CDII RP 2 verbally declined the flu vaccine because IP 1 was, Just going through the motions, was, Stressed out, and because there were so many residents IP 1 had to go through to schedule them for a flu clinic.

During a concurrent interview and record review on 1/15/2025 at 11:39 am with IP 1, IP 1 stated documenting flu declinations in a resident's CDII, which was part of the official medical record was willful falsification of medical records. IP 1 stated IP 1 was not supposed to document that IP 1 spoke to a resident or their RP when IP 1 did not because it was not correct documentation. IP 1 stated IP 1 knew IP 1 was documenting incorrect information.

During a telephone interview on 1/15/2025 at 2:52 pm, with RP 2, RP 2 stated facility staff did not call RP 2 to offer the flu vaccine for Resident 2 (during the current flu season).

During an interview on 1/15/2025 at 4:21 pm, with the Director of Nursing (DON), the DON stated the process for obtaining telephone flu vaccine consent was that two licensed nurses should be present during

the conversation with a RP when obtaining flu consent or declination to validate the consent or declination given by the RP. The DON stated if staff did not speak to RPs, they were supposed to document, unable to reach, or left voicemail, will attempt again later, in the resident's PN. The DON stated flu consents or declinations should be filled out in its entirety with the resident's name, RP name, date, time, licensed nurses' signatures along with the RP's full name, phone number, and that the consent or declination was obtained by telephone. The DON stated if licensed nurses did not speak to the RP when calling to offer the flu vaccine,

they were not supposed to document on the CDII the RP declined. The DON stated if licensed nurses documented they obtained consent or declination but did not speak to the resident or RP it was considered willful falsification of medical records. The DON stated willful falsification was wrong because it was a patient safety issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 2. During a concurrent interview and record review on 1/14/2025 at 5:08 pm, with IP 1, the facility's line list (a table that summarizes key information about each case during an OB) for the influenza was reviewed. The Level of Harm - Minimal harm or line listing was incomplete with missing information for Residents 1, 2, and 4. IP 1 stated the flu season potential for actual harm started on 10/1/2024 until 3/31/2025. IP 1 stated staff (licensed nurses) began offering the flu vaccine as early as late September and began administering the flu vaccine to residents as early as 10/1/2024. IP 1 Residents Affected - Some stated it was important to offer the flu vaccine at the beginning of each flu season to prevent residents from getting sick from the flu, or for the symptoms to be minimized. IP 1 stated the IPs (IPs 1 and 2) were not following the process and were not appropriately tracking residents' flu vaccine status because the facility was not organized. IP 1 stated IP 1 did not have an answer to why the facility was not following the facility's process for vaccinating residents. IP 1 and IP 2 stated the flu OB line list provided was not up to date (incomplete). IP 1 stated all residents were more susceptible to catching the flu because the IPs did not know what residents were vaccinated and what residents were not vaccinated.

During an interview on 1/15/2025 at 4:21 pm, with the DON, the DON stated a flu vaccine tracking system was important because it allowed for the facility to keep track of all residents' flu vaccination status. The DON stated when there was no tracking system or log in place, residents who were medically eligible to receive

the flu vaccine would not be offered the vaccine because of the facility's disorganization [lack of tracking].

During a review of the facility's P&P titled, Completion and Correction, revised 1/1/2012, the P&P indicated

the purpose was to ensure that medical records were complete and accurate, and that the facility would work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The P&P indicated entries would be complete, legible, descriptive, and accurate.

The P&P indicated an event was never supposed to be documented before it occurred.

During a review of the facility's P&P titled, Influenza Prevention and Control revised 9/10/2020, the P&P indicated residents were to be offered the influenza immunization every year during flu season, unless medically contraindicated, or the resident had already been immunized during the current flu season. The P&P indicated the resident's medical record would include documentation that indicated, at a minimum, the resident or the resident's representative was provided education regarding the risk and benefits and potential side effects of the influenza vaccination and whether the resident received the influenza vaccine, could not receive the vaccine due to a medical contraindication or refused the vaccine. The P&P indicated the vaccine type, dose, route, and nurse administering the vaccine would be documented on the medication administration record. The P&P indicated the vaccine lot number would be recorded on the immunization log.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46687 potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policies and procedures Residents Affected - Some (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) by failing to:

1. Ensure two of four certified nurse assistants (CNAs 2 and 4) wore appropriate PPE when entering Residents 13 and 14's rooms, who required patient care and were on EBP.

2. Ensure CNA 2 and CNA 4 performed hand hygiene before and after providing care to Residents 13 and 14 and before and after entering Resident 13 and 14's rooms.

These failures had the potential to transmit and spread infection from staff to residents that could result in widespread infection in the facility.

Findings:

a. During a review of Resident 14's Admission Record (AR), the AR indicated Resident 14 was admitted to

the facility on [DATE REDACTED], with diagnoses that included chronic respiratory failure (serious condition that makes it breathe on one's own), encounter for tracheostomy (incision made in the windpipe to relieve an obstruction to breathing), and ventilator (a machine that helps a resident breathe or breathes for the resident) dependence.

During a review of Resident 14's untitled care plan (CP), initiated 6/3/2024, the CP indicated Resident 14 was on EBP. The CP interventions included for staff to perform hand hygiene before and after patient contact, after contact with contaminated surfaces, and after removing gloves, wear gloves when in contact with blood, body fluids, mucous membranes, non-intact skin, and contaminated items, and use gowns to protect skin and clothing during procedures or activities where contact with body fluids or blood was anticipated.

During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/3/2024, the MDS indicated Resident 14 had moderately impaired cognition (ability to think, reason, and understand). The MDS indicated Resident 14 was dependent (helper does ALL of the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for oral and personal hygiene, toileting hygiene, upper and lower body dressing, rolling left and right (in bed), sitting to lying, and lying to sitting on

the side of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview on 1/14/2025 at 11:37 am with CNA 2, at Resident 14's doorway, CNA 2 was observed. A sign next to Resident 14's doorway indicated Resident 14 was on EBP. Level of Harm - Minimal harm or CNA 2 did not perform hand hygiene before entering the room. CNA 2 did not don (put on) gown or gloves potential for actual harm before entering the room. CNA 2 was observed touching Resident 14's linens and adjusting Resident 14's bedding. CNA 2 then moved Resident 14's tracheostomy tubing and adjusted the tracheostomy suction Residents Affected - Some catheter (mechanism and tubing used to remove mucous from the tracheostomy). CNA 2 then exited the room and did not perform hand hygiene.

During the same concurrent observation and interview on 1/14/2025 at 11:37 am with CNA 2, CNA 2 stated CNA 2 was, In the room really quick. CNA 2 stated adjusting Resident 14 (in bed), and touching tracheostomy tubing were examples of patient care. CNA 2 stated because CNA 2 was in the room, Really quick, and CNA 2 did not have to don PPE. CNA 2 stated the sign on the door indicated to perform hand hygiene. CNA 2 stated hand hygiene was important but did not state why.

b. During a review of Resident 13's AR, the AR indicated Resident 13 was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic respiratory failure, encounter for tracheostomy, and acute kidney injury (AKI- when the kidneys suddenly stop working due to complication of another serious illness).

During a review of Resident 13's MDS, dated [DATE REDACTED], the MDS indicated Resident 13 had moderately impaired cognition. The MDS indicated Resident 13 required substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing self, sitting to lying, and lying to sitting on side of bed.

During a review of Resident 13's untitled care plan (CP), initiated 6/3/2024, the CP indicated Resident 13 was on EBP. The CP interventions included for staff to perform hand hygiene before and after patient contact, after contact with contaminated surfaces, and after removing gloves, wear gloves when in contact with blood, body fluids, mucous membranes, non-intact skin, and contaminated items, and use gowns to protect skin and clothing during procedures or activities where contact with body fluids or blood was anticipated.

During a concurrent interview and record review on 1/14/2025 at 12:03 pm with CNA 4, at Resident 13's doorway, CNA 4 was observed. A sign next to Resident 13's doorway indicated Resident 13 was on EBP. CNA 4 did not perform hand hygiene before entering Resident 13's room. CNA 4 did not don gloves before entering the room. CNA 4 stated CNA 4 was going to perform patient care to Resident 13. CNA 4 stated CNA 4 was supposed to perform hand hygiene and don gloves before entering an EBP room to help prevent

the spread of infection. CNA 4 stated the sign on the door indicated to perform hand hygiene and don gloves and gown before entering the room.

During an interview on 1/14/2025 at 5:08 pm with Infection Preventionist (IP) 2, IP 2 stated any residents on EBP were at greater risk for developing infections due to their medical conditions. IP 2 stated staff were supposed to perform hand hygiene and don gloves and gown before entering the rooms of EBP residents and before providing patient care to residents on EBP. IP 2 stated if staff were not following EBP, residents were at risk for becoming infected with, getting from, and possibly being hospitalized or die from a MDRO.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/15/2025 at 4:21 pm with the Director of Nursing (DON), the DON stated staff were required to perform hand hygiene and wear all appropriate PPE before providing care to residents on EBP. Level of Harm - Minimal harm or The DON stated adjusting residents in bed, moving tracheostomy tubing and suction catheters, and moving potential for actual harm residents' linens were examples of patient care. The DON stated EBP kept vulnerable residents who had many medical issues safe from the spread of infection by proactively protecting them from colonization of Residents Affected - Some potential MDRO. The DON stated if staff did not follow EBP, residents were at risk for developing MDRO infections and developing complications that could lead to hospitalization or even death.

During a review of the facility's P&P titled, Hand Hygiene, revised 9/1/2020, the P&P indicated, The facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub 9 (ABHR) including foam or gel. The P&P indicated, Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors . The P&P indicated, The following situations require appropriate hand hygiene: i.

Before eating, ii. After using the bathroom, iii. After contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage, and soiled dressing, iv. Before and after food preparation, v. Before and after assisting a Resident with dining if direct contact with food is anticipated or occurs, vi. Before donning and after doffing Personal Protective Equipment (PPE), vii. Immediately upon entering and exiting a resident room .

During a review of the facility's P&P titled, Enhanced Barrier Precautions (EBP), revised 7/5/24, the P&P indicated, When Transmission-based precautions (TBP- a set of infection control measures used in healthcare to prevent the spread of infection) are not appropriate and in addition to Standard Precautions, EBP will be used for novel (new) or targeted MDROs in the facility, based on the Centers for Disease Prevention and Control (CDC) guidance. The P&P indicated, Purpose . To reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. The P&P indicated, Many residents

in nursing homes (skilled nursing facilities) are at increased risk of becoming colonized (infected) and developing infections with MDROs. The P&P indicated, .EBP is employed when performing the following high-contact resident care activities .: a. Dressing, b. Bathing/showering, c. Transferring within the resident room, d. Providing hygiene e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: ( .tracheostomy/ventilator). The P&P indicated, Required PPE . gloves and gown prior to the high contact care activity .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46687 jeopardy to resident health or safety Based on interview and record review, the facility failed to prevent and control the spread of Influenza (flu, highly contagious, sometimes deadly respiratory infection [the invasion and growth of germs in the lungs and Residents Affected - Some the airway, caused by the influenza virus) for 7 of 15 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7)

during the current flu season (from 10/1/2024 to 3/31/2025) in according to the facility's policy and procedure (P&P) titled, Influenza Prevention and Control, by failing to:

1. Ensure Infection Preventionists (IPs, a healthcare professional who specializes in preventing the spread of infections in healthcare settings) 1 and 2 provided information/education regarding the benefits, risks, and

the potential side effects (injuries resulting from medication use including physical and mental harm, or loss of function) of the flu vaccine (an injection administered to lower the risk of contracting the flu) and providing

an opportunity to decline (choosing not to accept the influenza vaccine) or accept the vaccine for Residents 1, 2, 3, 4, 5 and 6) and/or their responsible parties (RP) for the flu season that began on 10/1/2024.

2. Ensure IP 1, and IP 2 administered the flu vaccine to Resident 7 after Resident 7 consented to receive the flu vaccine on 12/18/2024.

3. Ensure the facility had a system in place to track Residents 1, 2, 3, 4, 5, 6 and 7's flu vaccination status for

the current flu season.

As a result of these failures, Residents 1, 2, 3, 4, 5, and 6 were not offered the flu vaccine, and Resident 7 was consented for the flu vaccine (on 12/18/2024) but did not receive the vaccine after consenting to receive

the flu vaccine. Residents 1, 2, 3, 4, 5, 6, and 7 being diagnosed with the flu and the residents had respiratory symptoms (symptoms that affect the lungs and or the airways). Residents 1, 2, 3, 4, 6, and 7 were hospitalized due to sepsis (a serious condition in which the body responds improperly to an infection) and/or pneumonia (PNA, an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus that can be life-threatening). These failures also had the potential to place Residents 1, 2, 3, 4, 5, 6, and 7 at risk for respiratory illness complications that could lead to serious injuries, harm, and or death.

On 1/15/2025 at 7:09 pm, while at the facility, the surveyors called an Immediate Jeopardy [IJ, a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to offer/administer flu vaccines for Residents 1, 2, 3, 4, 5, 6 and 7. The facility also failed to have a system in place to track resident vaccination status for Residents 1, 2, 3, 4, 5, 6 and 7 as indicated in Title 42, the Federal Code of Regulation (CFR) S483.80(d)(1) Influenza.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 On 1/16/2025, the facility submitted an IJ Removal Plan (IJRP, plan that includes interventions to immediately correct the deficient practices). While onsite at the facility, the surveyors verified the IJ situation Level of Harm - Immediate (failure to offer/administer flu vaccines) was no longer present and confirmed the facility's implementation of jeopardy to resident health or the IJRP through observations, interviews, and record review. The IJ was removed on 1/16/2025 at 6:53 pm, safety in the presence of the ADM, the DON, and the Assistant Director of Nursing (ADON).

Residents Affected - Some The acceptable IJRP included the following immediate actions:

1. On 1/15/2025, IP 1 and IP 2 were immediately placed on administrative suspension, pending investigation.

2. On 1/15/2025, The ADM promoted a Licensed Vocational Nurse (LVN) to be the interim (temporary) IP (IP 3). IP 3 had received the Infection Prevention Training for Skilled Nursing Facilities, as well as worked as an Infection Prevention & Control Nurse at another facility. Effective immediately, the DON will be responsible for the oversight of the Infection Prevention & Control Program for compliance by conducting weekly compliance audits and verification.

3. On 1/15/2025, the following actions were immediately completed for Residents 1, 2, 3, 4, 5, and 6 related to influenza vaccine offering and administration:

a. Resident 1: On 1/15/2025, the influenza vaccine was offered to Resident 1's RP (RP 1) who consented to receive the flu vaccine. Resident 1 received the flu vaccine on 1/15/2025.

b. Resident 2: On 1/15/2025, at 10:26 pm, the DON contacted Resident 2's PR (RP 2) to verify Resident 2's influenza vaccination status and left a voice message. On 01/16/2025 at 8:57 am, the ADON called RP 2 and received a declination for the seasonal Influenza vaccine.

c. Resident 3: On 1/15/2025, the influenza vaccine was consented by Resident 3's representative the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward resident goals) Resident 3 received the flu vaccine on 1/15/2025.

d. Resident 4: On 1/15/2025, the influenza vaccine was offered to Resident 4, who consented to receive the flu vaccine. Resident 4 received the flu vaccine on 1/15/2025.

e. Resident 5: On 1/15/2025, the influenza vaccine was consented by the RP 5 (IDT) as the resident's representative. Resident 5 physically did not allow the nurses to administer the seasonal Influenza vaccine.

On 1/15/2025, Resident 5's attending physician was notified.

f. Resident 6: On 1/16/2025, the influenza vaccine was offered to Resident 6's RP (RP 6) who consented to receive the flu vaccine. Resident 6 received the flu vaccine on 1/16/2025.

4. Resident 7 remained hospitalized as of 1/15/2025.

5. On 01/15/2025, the ADM, the DON, and the Medical Director conducted a Quality Assurance Performance and Improvement (QAPI, a process that aims to improve the quality of healthcare and safety of patients/residents) meeting to discuss Infection Prevention and Control concerns related to influenza vaccination including screening, offering, tracking, and monitoring of influenza vaccine status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 555852 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555852 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Avenue Healthcare & Wellness Center 1550 North Park Avenue Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 6. On 1/15/2025, the DON, and ADON conducted an audit of current residents and revalidated the consents for influenza immunizations. The DON and ADON initiated verification of influenza vaccine declinations. Level of Harm - Immediate jeopardy to resident health or 7. On 1/15/2025, the ADM and DON initiated an in-service education to the licensed nurses (all licensed safety nurses) regarding the P&Ps for Influenza Prevention and Control.

Residents Affected - Some 8. On 01/15/2025, the ADM contacted the Pharmacy Representative to reserve 50 doses of the seasonal Influenza vaccine, which was delivered on 1/15/2025.

Cross Reference