Green Acres Lodge

F-F740

Findings:

1. A review of Resident 9's Admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought).

A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated that Resident 9's cognition (mental action or process of acquiring knowledge and understanding) was intact.

The MDS indicated that Resident 9 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities.

A review of Resident 9's Change of Condition (COC) assessment, dated 1/16/2025 and 1/28/2025, indicated that Resident 9 showed an aggressive behavior towards the staff and residents. The COC on 1/16/2025 indicated that Resident 9 was trying to attack the staff and residents and went to the room of other residents to take their personal belongings. The COC on 1/28/25 indicated that Resident 9 was again trying to strike out at the staff and residents.

A review of Resident 9's medical records indicated that the facility did not create a care plan for Resident 9 ' s COC on 1/16/2025 when Resident 9 tried to attack the staff and residents and went to the rooms of other residents to take their personal belongings.

A review of Resident 50's Admission Record indicated that the facility initially admitted on [DATE REDACTED] and readmitted the resident on 3/13/2025 with diagnoses that included schizophrenia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0656 A review of Resident 50's MDS, dated [DATE REDACTED], indicated that Resident 50's cognition was moderately intact.

The MDS indicated that Resident 50 required partial/moderate assistance (helper does less than half the Level of Harm - Minimal harm or effort of the task) from a person when performing most of her daily living activities. potential for actual harm

During an interview with Resident 50 on 2/5/2025 at 10:50 AM, she stated that about three weeks ago, Residents Affected - Few Resident 9 went to her room, took her pillow, and left. Resident 50 stated that on 2/4/2025, Resident 9 went back to her room, stood at the doorway, and refused to leave when she asked her to go back to her room. Resident 50 stated that she reported the incident to one of the licensed nurses.

During an interview with licensed vocational nurse (LVN) 4 on 2/5/2025 at 1:51 PM, LVN 4 stated that she initiated a COC for Resident 9 on 1/16/2025 since Resident 9 became physically and verbally aggressive towards the staff and other residents; however, she stated that Resident 9 did not have physical contact with any resident. LVN 4 stated that Resident 9 also went to the rooms of other residents on the same day and took their personal belongings.

During an interview with LVN 1 on 2/5/2025 at 1:58 PM, LVN 1 stated that she initiated a COC for Resident 9

on 1/28/2025 since Resident 9 became physically aggressive towards the staff and other residents; however, LVN 1 stated that Resident 9 did not have physical contact with any resident.

During an interview and a record review of Resident 9's medical records with the director of nursing (DON)

on 2/7/2025 at 7:50 AM, the DON stated that the facility did not conduct an interdisciplinary team (IDT, a group of professionals from different disciplines who work together collaboratively to achieve a common goal) meeting or created a care plan to address Resident 9's behavior on 1/16/2025. The DON stated that

the facility should have conducted an IDT meeting and created a care plan for Resident 9 to ensure the safety of the residents, prevent harm, and promote dignity and privacy among the residents.

A review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered, version 2.0, revised in 3/2022, indicated that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, should develop and implement a comprehensive, person-centered care plan to meet the physical and psychosocial needs of each resident.

48481

2. During a review of Resident 226 ' s Admission Record indicated Resident 226 was admitted to the facility

on [DATE REDACTED], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty

in blood sugar control, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.)

During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing.

During a review of Resident's 226's Care Plan dated 1/10/25, indicated Resident 226 was at risk of having needs unmet related to difficulty in communication secondary to hard of hearing and spoke a foreign language.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0656 1. Resident will be able to relate to others effectively daily until the next assessment.

Level of Harm - Minimal harm or 2. Resident will have communication needs met by use appropriate interventions daily until the next potential for actual harm assessment.

Residents Affected - Few During a concurrent observation and interview 2/5/2025 at 9:05 AM, Resident # 226 was observed writing on

a piece of paper in foreign language back and forth with Certified Nursing Assistant (CNA) 1. Resident 226 stated the communication has been difficult between her and staffs, because she has hard of hearing (HOH) and she and the staffs do not understand each other sometimes with her limited English. Resident 226 stated there were times that staffs who didn't understand her language walked out of the room and did not come back. Resident 226 stated she had never been offered communication board, audio or video materials

in the language that she speaks. Resident 226 was observed expressing frustration, weeping, and stated

she suffered a lot because of poor communication and her needs were not met.

During an interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 stated Resident 226 has HOH, speaks limited language that the facility uses, CNA 1 stated she communicates to the resident in writing when she was called to help translate in the language that the residents speak. CNA1 also stated she had noticed Resident 226 expressed sadness and frustration when complaining to her about not understanding the staffs and not being understood by the staffs.

During an interview on 2/5/25 at 9:35AM, with Licensed Vocational Nurse (LVN )4, LVN 4 stated she communicated with Resident 226 via phone translation (connect with a live interpreter via phone for real-time translation), and she was aware the Resident 226 had HOH, and has language communication barrier, sometimes staffs assist translation, LVN 4 stated there was no communication board available at bedside for Resident 226 to use, and stated she does not use phone translation due to Resident 226 had a HOH so the method was not very effective.

During an interview on 2/6/25 at 11:00 AM with Registered Nurse (RN) 2, RN 2 stated he uses body language, to communicate with Resident 226. RN 2 stated there was no communication board available. RN 2 stated he couldn ' t always ensure if Resident 226 understood him, sometimes based on translator ' s feedback.

During a review of Resident 226 ' s Licensed Nurses Notes, dated 1/9/25 throughout 2/4/25, no documented evidence that indicated a translator and/or communication board was provided to the resident in a foreign language that the resident speaks and understands.

During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory or language barrier, admission nursing staff should identify the risk factors, residents ' needs, develop and implement a person-centered care plan. Failure to communicate effectively between staffs and residents will impair resident rights. Communication is important, staffs should have properly assessed Resident 226 ' s needs, developed and implemented comprehensive care plan, and used effective communication methods to ensure staffs understand her, and Resident 226 can relate to the staffs. It's totally not acceptable to have resident's rights compromised due to any barrier.

During a review of the facility ' s policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/2022, indicated The comprehensive, person-centered care plan:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0656 a. Includes measurable objectives and timeframes.

Level of Harm - Minimal harm or b. Describe services that are to be furnished to attain or maintain the resident ' s highest practicable physical, potential for actual harm mental, and psychosocial well-being.

Residents Affected - Few c. Builds on the resident ' s strengths.

Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and relevant clinical decision making.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48481 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident received proper Residents Affected - Few assistive devices to maintain hearing abilities for one of 3 sampled residents (Resident 226) who was not assisted by the facility in arranging a referral for audiologist (a physician specialized in hearing loss) consult.

This deficient practice resulted in a delay of services and Resident 226 not being able to hear adequately while communicating with staffs.

Findings:

During an observation on 2/4/25 at 8:33 AM, Resident 226 was observed alert, lying in bed, with a raised voice speaking to a laboratory staff, who also had to raise volume for Resident 226 to hear the resident. Resident 226 also pulled out pieces of paper and requested to communicate in writing.

During an interview on 2/4/25 at 9:31 AM, Resident 226 stated she has hard of hearing (HOH), has no device, to assist her with the difficulty hearing whatever the staffs say to her.

During a concurrent observation and interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 was observed writing on a paper to communicate with Resident 226, CNA 1 stated writing works better than speaking to Resident 226. CNA1 also stated aware that Resident 226 has HOH, speaks limited language formally used

in the facility. CNA 1 stated she was often called by staffs to Resident 226 ' s room to help translate in a language that the resident speaks and understands. CNA 1 stated she often hear Resident 226 complained not understanding the staffs and not being understood.

During an interview on 2/5/25 at 9:20 AM, LVN 5 stated she aware that Resident 226 was HOH, and has language barrier. LVN 5 stated sometimes she use body gestures to communicate with the resident but can ' t be sure if Resident 226 fully understood what she ' s trying to tell Resident 226.

During a review of Resident 226's Admission Record indicated Resident 226 was admitted to the facility on [DATE REDACTED], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Unspecified Dementia (a progressive state of decline in mental abilities), abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.)

During a review of Resident 226's Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing.

During a review of a physician order dated 1/9/25, indicated Resident 226 was referred to Audiology consult PRN (as needed) for hearing problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0685 During a concurrent interview and record review on 2/6/25 at 8:50 AM with Social Service Director (SSD). SSD stated spoke to Resident 226 and her responsible party upon admission. SSD stated Resident 226 did Level of Harm - Minimal harm or not have hearing disability, that ' s why ENT (Ear, Nose, Throat) doctor appointment arranged set up potential for actual harm necessary. No staffs reported SSD re: hearing disability.

Residents Affected - Few During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory barrier, the SSD has to do the assessment, MDS also assess resident upon admission, and reassess if there's discrepancy in the assessments. Then SSD arrange audiology consult and make appointment for resident. Failure to report resident ' s needs for specialty consultation delay the care and services, and impaired resident rights. Communication is important, staffs should have properly assessed Resident 226 ' s needs and used effective communication methods to ensure resident can understand. It's totally not appropriate to have resident's care delayed due to any barrier.

During a review of the facility's policy and procedure titled Accommodation of Needs Related to Communication Deficits revision date 3/2021, indicated Communication needs will be identified, and appropriate interventions will be developed in order to accommodate the needs of the residents. Communication needs will be assessed as follows:

a. Psycho-Social Assessment form; Resident Identifying Date- Language Spoken

b. Rehabilitation Screening- Mode of Expression, etc

c. Communication Section on Social Service Progress Notes.

During a review of the facility's policy and procedure titled Accommodation of Needs, revision dated 3/2021, indicated that facility ' s environment and staff behavior are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The resident ' s individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. Interact with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47882

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received appropriate treatment and services to prevent urinary tract infection (UTI-when bacteria gets into your urine and travels up to your bladder), in accordance with the facility's policy and procedures (P&P) on Infection Prevention and Control Program.

1. On 2/4/2025, Resident 3 was observed while sitting on his wheelchair, Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) drainage bag (urine drainage bag to collect urine) was hanging on the wheelchair ' s left arm rest (positioned higher than Resident 3's bladder).

2. On 2/5/2025, Resident 3 was observed with the suprapubic catheter tubing wrapped around his left leg while sitting on his wheelchair.

This deficient practice had the potential for Resident 3 to have recurrent urinary tract infection and negatively affect Resident 3's quality of life.

Findings:

During a review of Resident 3's, Admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (Obstructive uropathy happens when urine can't flow through

the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection (UTI).

During a review of Resident 3's History and Physical Examination (H&P), dated 12/3/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.

During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3's cognitive status (the mental process of thinking and understanding) was severely impaired. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing.

During a review of Resident 3's care plan (CP) for suprapubic catheter, at risk for complication from catheter use (i.e. recurrent urinary tract infection) initiated 12/27/2019, the CP indicated staff to maintain proper alignment of the suprapubic catheter to promote proper drainage.

During a review of Resident 3's facility document titled NC-COC/Interact Assessment Form (SBAR), dated 9/14/2022, the document indicated Resident 3 had a UTI and was placed on antibiotic (medicines that fight bacterial infections) therapy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0690 During a review of Resident 3's Order Summary Report (OSR), dated 2/1/2025, the OSR indicated, an order date of 11/30/2024 the use of suprapubic catheter attached to drainage bag for obstructive and reflux Level of Harm - Minimal harm or uropathy. potential for actual harm

During a concurrent observation and interview on 2/4/2025 at 10:15 AM with Registered Nurse (RN) 1 in the Residents Affected - Few Dining Room, Resident 3 was sitting on his wheelchair, his suprapubic catheter drainage bag was hanging

on the wheelchair's left armrest (positioned higher than Resident 3's bladder). RN 1 stated, the urinary drainage bag should not be hanging on the armrest, it should be under the wheelchair seat and must be positioned lower that Resident 3's bladder. RN 1 stated, the position of the urinary drainage bag could cause backflow of urine back to Resident 3's bladder and can cause UTI.

During a concurrent observation and interview on 2/5/2025 at 8:20 AM with Licensed Vocational Nurse (LVN) 1, and Certified Nurse Assistant (CNA) 1 in Resident 3 ' s room, Resident 3 while sitting on his wheelchair, noted his suprapubic catheter tubing was wrapped around his left leg. CNA 1 did not have an answer to why

the suprapubic catheter tubing was wrapped around Resident 3's left leg, LVN 1 stated, Resident 3's suprapubic catheter tubing wrapped around his leg is not appropriate, the urine will not flow freely and could cause backflow to Resident 3's bladder and had the potential to cause UTI.

During an interview on 2/5/2025 at 2:05 PM with the Infection Preventionist (IP), the IP stated, the suprapubic catheter urinary bag should always be positioned below the resident's bladder. The IP stated the suprapubic catheter tubing should not be wrapped around residents' leg because these practices could cause back flow to Resident 3's bladder and had the potential to cause UTI.

During an interview on 2/5/2025 at 2:25 PM with the Director of Nurses (DON), the DON stated, the suprapubic catheter urinary bag should not be hanging on Resident 3's wheelchair arm rest, it should always be positioned below Resident 3's bladder, and the tubing should not be wrapped around Resident 3's leg, otherwise it could cause backflow to Resident 3's bladder and cause UTI.

During a review of the facility's P&P titled, Suprapubic Catheter Care, dated 10/2010, the P&P indicated; a)the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of

the resident ' s urinary tract, b) to review the resident ' s care plan to assess for any special needs of the resident and c) the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

During a review of the facility's P&P titled, Infection Prevention and Control Program revised 4/2023, the P&P indicated; a) the facility established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and b) important facets of infection prevention include instituting measures to avoid complications or dissemination (to spread or scatter).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm 36925

Residents Affected - Few Based on interview and record review, the facility failed to implement its policy and procedure on behavioral health services by failing to provide one of two sampled residents (Resident 9) a referal to psychiatrist (a physician specialized in mental and behavioral health) consultation evaluation for aggressive behavior towards the staff and residents to attain the resident's highest practicable physical, mental, and psychosocial well-being.

This deficient practice had the potential to worsen the mental health symptoms of the resident, increase risk of relapse, decrease quality of life, and increase the likelihood of needing more intensive interventions like hospitalization in the future.

Findings:

A review of Resident 9's Admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought and false belief of reality).

A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated that Resident 9's cognition (mental action or process of acquiring knowledge and understanding) was intact.

The MDS indicated that Resident 9 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities.

A review of Resident 9's Change of Condition (COC) assessment, dated 1/16/2025 and 1/28/2025, indicated that Resident 9 showed an aggressive behavior towards the staff and residents. The COC dated 1/16/2025 indicated Resident 9 was trying to attack the staff and residents, went to a resident's room, and took the personal belongings of another resident. The COC on 1/28/2025 indicated that Resident 9 was again trying to strike out at the staff and residents.

A review of Resident 9's medical records indicated that the facility created a care plan on 1/28/2025 to address Resident 9's aggressive behavior towards the staff and residents. The interventions in the care plan included a consultation with a psychiatrist to evaluate the resident 's behavior.

During an interview with Licensed Vocational Nurse (LVN) 4 on 2/5/2025 at 1:51 PM, LVN 4 stated that she initiated a COC on 1/16/2025 since Resident 9 became physically and verbally aggressive towards the staff and other residents.

During an interview with LVN 1 on 2/5/2025 at 1:58 PM, LVN 1 stated that she initiated a COC on 1/28/2025 since Resident 9 became physically aggressive towards the staff and other residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0740 During an interview and a record review of Resident 9's medical records with the Director of Nursing (DON)

on 2/7/2025 at 7:50 AM, the DON stated that the facility created a care plan on 1/28/2025 to address the Level of Harm - Minimal harm or aggressive behavior of Resident 9 with an intervention to consult a psychiatrist to evaluate the resident. The potential for actual harm DON stated that the facility overlooked that intervention and failed to refer Resident 9 to the psychiatrist.

Residents Affected - Few A review of the facility's undated policy titled, Behavioral Health Services, version 1.0, revised in 2/2019, indicated that the facility would provide residents with behavioral services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident in accordance with the comprehensive assessment and plan of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 36925 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a medication error rate of Residents Affected - Few less than five (5) percent (%) during medication pass by committing four (4) medication errors on one of six sampled residents (Resident 15) during medication observation with 29 medication opportunity that resulted to a 13.79% medication error rate.

This deficient practice had the potential to result in adverse reaction) undesired effect of a drug or other type of treatment) to the medications that could jeopardize the safety of the residents that could lead to serious harm, injury, or death.

Findings:

A review of Resident 15's Admission Record indicated that the facility initially admitted Resident 15 on 4/3/2024 and readmitted the resident on 10/9/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought).

A review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 12/27/2024, indicated that Resident 15's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired.

A review of Resident 15's Order Summary Report, indicated that as of 2/1/2025, the physician ordered to administer the following medications to Resident 15:

1. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle (used to treat seizure disorders and mental/mood conditions) 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). Give one capsule by mouth two times a day.

2. Docusate Sodium (a stool softener to treat constipation) Oral Tablet 100 mg. Give one tablet by mouth one time a day.

3. Multivitamin-Minerals (a combination of vitamins and minerals to prevent nutrient deficiencies) Oral Tablet. Give one tablet by mouth one time a day.

4. Sodium Chloride (an electrolyte replenisher) Oral Tablet 1 gram (metric unit of measurement, used for medication dosage and/or amount). Give one tablet by mouth one time a day.

During a medication administration observation on 2/6/2025 at 8:42 AM, LVN 3 prepared four (4) oral medications (Docusate Sodium tablet, Depakote Sprinkles capsule, Multivitamin-Minerals tablet, and Sodium Chloride tablet), crushed them, and mixed them in a single container with apple sauce. The surveyor interrupted LVN 3 before she was about to administer the medications to Resident 15.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0759 During a concurrent interview with LVN 3, she stated that she realized she was not supposed to mix the medications all together. LVN 3 stated that Resident 15 would not know what medication she would be Level of Harm - Minimal harm or taking if she crushes and mixes them. potential for actual harm

During an interview on 2/7/2025 at 1:46 PM, the director of nursing (DON) stated that ideally, the licensed Residents Affected - Few nurse should administer crushed medications separately, unless the resident wants to take them all together

in a single container. The DON stated that it is a matter of resident preference whether to administer crushed medications individually or separately.

A review of the facility's undated policy titled, Administering Medications, version 2.1, revised in 4/2019, indicated that medications should be administered in a safe and timely manner. The policy did not have a specific instruction or procedure on how to properly administer crushed medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 36925 Residents Affected - Few Based on observation, interview, and record review, the facility failed to implement its policy and procedure

on how to properly and safely store medications and biologicals by failing to separately store Hydrogen Peroxide Topical Solution (an external [outside the body] medication with mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) on the same shelf with oral (medications given by mouth) medications such as stool softeners and vitamins.

This deficient practice had the potential to cause medication errors and expose residents to adverse reactions (an undesired harmful effect) that could lead to serious harm or death.

Findings:

During an inspection of the facility's East Wing medication storage room with licensed vocational nurse (LVN) 3 on 2/6/2025 at 10:05 AM, a bottle of Hydrogen Peroxide Topical Solution, an external (applied outside the body) medication used on the skin to prevent infection of minor cuts, scrapes, and burns, was observed on

the same shelf where oral medications were kept.

During a concurrent interview with LVN 3, LVN 3 stated that the facility should not store external medications

on the same shelf where oral medications are kept to prevent medication errors.

During an interview on 2/7/2025 at 1:56 PM, the director of nursing (DON) stated that the facility should keep oral medications and external medications separately to avoid medication errors. The DON stated that storing oral and external medications together increases the risk of misidentification and accidental ingestion of an external medication, especially if the containers look similar. The DON stated that he did not know who placed the external medication on the same shelf where oral medications were stored.

A review of the facility's undated policy titled Medications Storage in the Facility, effective 4/2008, indicated that medications and biologicals should be stored safely, securely, and properly. The policy indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48481

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure one of the two refrigerators (located in the temporary food storage room at nearby facility) temperatures were monitored and documented before and between meal service activities for stable temperatures.

This deficient practice placed the facility residents at risk for foodborne illness an (illness that comes from eating contaminated food) due to inconsistent refrigerator temperature monitoring and documentation.

Findings:

During a follow up kitchen tour on 2/6/25 at 12PM with the Dietary Service Supervisor (DSS) in the temporary food storage room located outside the kitchen, three (3) refrigerators and one (1) freezer were observed in this storage room. Each was observed with one thermometer inside. A Refrigerator and Freezer Temperature Log for February 2025 was observed hanging on the door. The log for 2/4/25 PM through 2/6/25 for Refrigerator 2 was blank. The log for Refrigerator 3 and Freezer was blank from 2/4/25 through 2/6/25.

During an interview with on 2/6/25 at 12:10 PM, the DDS stated that the cooks for AM and PM shift are designated for checking all the temperature in the refrigerators and freezers and logs. DSS stated she was not sure if the cooks checked the logs, but the DDS should have not missed daily inspection of the logs. DSS also stated she was responsible for checking the logs and supervising the staffs for keep the log to ensure all

the temperature in the refrigerators and freezers being monitored for safe food storage.

During a review of the facility's policy and procedure titled, Refrigerators and Freezers dated 11/2022, indicated Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken, The last column will be completed only if temperatures are not acceptable. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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** 47882 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a system in preventing, Residents Affected - Few controlling infections and communicable diseases were in place, when one of two sampled residents (Resident 3) according to the facility's Infection Prevention and Control Program.

Resident 3 who was on an enhance barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) due to a suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) was observed receiving high contact care (fixing Resident 3 ' s suprapubic catheter tubing and urine drainage bag) from Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1). LVN 1 and CNA 1 failed to use an isolation gown as part of their PPE (Personal Protective Equipment) and proceeded to the Nurses Station without performing hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) after the care.

These deficient practices had the potential to cause and/or spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility.

Findings:

During a review of Resident 3's, Admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (Obstructive uropathy happens when urine can't flow through

the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection.

During a review of Resident 3's History and Physical Examination (H&P), dated 12/3/2024, indicated Resident 3 does not have the capacity to understand and make decisions.

During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3's cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half

the effort) with bathing.

During a review of Resident 3's care plan (CP) for suprapubic catheter, at risk for complication from catheter use (i.e. recurrent urinary tract infection) revised 1/31/2025, the CP indicated intervention included Enhance Standard Precaution due to status post suprapubic catheter.

During a review of Resident 3's care plan (CP) for Enhance Barrier Precaution due to suprapubic catheter use, revised 1/31/2025, the CP indicated interventions that included hand hygiene during any direct contact, and providing enhance standard precaution gloves, gowns, mask.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 review of Resident 3's Order Summary Report (OSR), dated 2/1/2025, the OSR indicated; a) an order date of 11/30/2024 the use of suprapubic catheter attached to drainage bag for obstructive and reflux Level of Harm - Minimal harm or uropathy, and b) an order date of 12/2/2024, Resident 3 was placed on Enhanced Barrier Precautions due to potential for actual harm suprapubic catheter in place.

Residents Affected - Few During an observation on 2/5/2025 at 8:30 AM in Resident 3's room, Resident 3, who was on an Enhance Barrier Precaution, was receiving a high contact care (fixing Resident 3's suprapubic catheter tubing and urine drainage bag) from two nursing staff (CNA 1 and LVN 1), both nursing staff was not wearing a gown as part of their PPE, then both staff proceeded to the nurses station after the care without performing hand hygiene.

During an interview on 2/5/2025 at 8:45 AM with CNA 1, CNA 1 did not have an answer to why she did not wear a gown as part of her PPE prior to taking care of Resident 3, and not performing hand hygiene after taking care of Resident 3.

During an interview on 2/5/2025 at 8:50 AM with LVN 1, LVN 1 stated, she was aware that she was supposed to wear a gown as part of her PPE when she took care of Resident 3 who was on EBP, and she was also aware that she was supposed to perform hand hygiene after providing care to Resident 3, she just forgot. LVN 1 stated, not using PPE prior to taking care of Resident 3 and not performing hand hygiene after providing care to Resident 3 had the potential to spread virus and bacteria in the facility.

During an interview on 2/5/2025 at 2:05 PM with Infection Preventionist (IP), IP stated, Resident 3 is on enhance barrier precaution because he has a suprapubic catheter, as per policy staff should use PPE's which includes wearing a gown prior to direct care to the resident and practice hand hygiene before and after direct care to Resident 3. IP stated, adhering to EBP policy is for the protection of Resident 3 and other residents and staff, not following the enhance barrier precaution had the potential to cause the spread of virus, bacteria and multi-drug-resistant organisms (MDROs) in the facility

During an interview on 2/5/2025 at 2:25 PM with the Director of Nurses (DON), the DON stated, Resident 3 is on an enhance barrier precaution, which means when staff has high contact care with the resident the staff should wear PPE's which includes gloves and gown and perform hand hygiene before and after the care of Resident 3. DON stated, performing care with Residents 3's suprapubic catheter tubing and urine drainage bag are considered high contact care. DON stated, LVN 1 and CNA 1 should have been wearing a gown prior to Resident 3's care and should have performed hand hygiene after the care, these mistakes of the staff had the potential to cause the spread of virus, bacteria and MDROs in the facility.

During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 6/5/2024, the P&P indicated; a) Enhance barrier precaution are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents, b) gloves and gown are applied prior to performing the high contact resident care activity, and c) example of high-contact resident care activities requiring the use of gowns and gloves for EBP included device care or use (urinary catheter).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 4/2023, the P&P indicated; a) the facility established and maintained to provide a safe, sanitary, and Level of Harm - Minimal harm or comfortable environment and to help prevent the development and transmission of communicable diseases potential for actual harm and infections and b) important facets of infection prevention include instituting measures to avoid complications or dissemination (to spread or scatter). Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47882

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure three of 40 resident rooms (Rooms 6, 15. and 26) did not accommodate more than four residents per room.

This deficient practice had the potential to affect the health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the residents.

Findings:

On 2/4/2024, the Administrator (ADM) submitted a written room waiver request for three resident rooms, which had five resident beds in each room. A review of the letter for room waiver indicated the following:

Room # Number of beds square feet (sq. ft)

6 5 332.5 sq. ft

15 5 441 sq. ft

26 5 496 sq. ft

A review of the room waiver request indicated the residents' needs were accommodated and there were no adverse effects (undesired outcome) to the health, safety, and welfare to the residents occupying these rooms. The maximum number of beds allowed in a multiple resident bedroom should be no more than four beds per room.

During a tour of the facility conducted on 2/7/2025 at 9AM, Residents in rooms. 6, 15, and 26 were observed without difficulty getting in and out of their bedrooms. The nursing staff had full access to provide treatment, administer medications and assist residents to perform their individual routine activities of daily living.

1. During a review of Resident 67's Admission Record indicated the facility originally admitted Resident 67

on 2/24/2024 and readmitted on [DATE REDACTED] with diagnoses that included kidney failure (kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance, hypertension (elevated blood pressure), and depression (a low mood or loss of pleasure or interest in activities for long periods of time).

During a review of Resident 67's Minimum Data Set (MDS, a Resident assessment tool), dated 1/16/2025, indicated Resident 67 cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 67 required set up or clean-up assistance (helper sets up or clean up resident; resident completes activity. Helper assists only prior to or following the activity) with eating, toileting and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0911 During an interview on 2/7/2025 at 9:05 AM, Resident 67, stated he had enough room to do the things he wanted to do, and did not mind sharing the room with other residents. Level of Harm - Potential for minimal harm 2. During a review of Resident 36's Admission Record indicated the facility originally admitted Resident 36

on 3/31/2014 and readmitted on [DATE REDACTED] with diagnoses that included encephalopathy (a disease, disorder, Residents Affected - Some or damage that affects the brain's structure or function), seizures (a brief episode of abnormal electrical activity in the brain that causes temporary changes in behavior and movement), and depression.

During a review of Resident 36's Minimum Data Set, dated dated [DATE REDACTED], indicated Resident 36 cognitive skills was intact. The MDS indicated Resident 36 required set up or clean-up assistance with eating, and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with toileting and personal hygiene.

During an interview on 2/7/2025 at 9:10 AM, Resident 36, stated he had no issues with room space and did not mind sharing the room with other residents.

3. During a review of Resident 20's Admission Record indicated the facility admitted Resident 20 on 9/27/2024 with diagnoses that included cerebral atherosclerosis (a disease that occurs when the arteries in

the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls), encephalopathy, and Rhabdomyolysis (a rare but serious condition that occurs when muscle tissue breaks down and releases harmful substances into the blood).

During a review of Resident 20's Minimum Data Set, dated dated [DATE REDACTED], indicated Resident 20 cognitive skills was intact. The MDS indicated Resident 20 required set up or clean-up assistance with eating, toileting and personal hygiene.

During an interview on 2/7/2025 at 9:15 AM, Resident 20, stated he had no concerns with his room space and roommates.

During an interview on 2/7/2025 at 10:00 AM, certified nurse assistant (CNA) 2, stated she had enough room to take care of the residents and residents had no concern about room space.

During an interview on 2/7/2025 at 10:05 AM, Licensed Vocational Nurse (LVN) 2, stated she had enough room to do her care and have not heard any concern from residents about room space.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47882

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the resident ' s bedrooms measure at least 100 square feet (sq. ft) per resident in a single resident room or measure at least 80 sq. ft.

In multiple resident's room for four of 12 single rooms (Rooms 4, 5, 16 and 17).

This deficient practice had the potential to affect the quality of care, health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the resident.

Findings:

On 2/4/2025, the Administrator submitted a written room waiver request for four single bedrooms, which Included the square footage of each room. A review of the waiver letter Indicated the following:

Room # # Beds square feet (sq. ft.)

4 1 76.00 sq. ft.

5 1 76.00 sq. ft.

16 1 99.75 sq. ft.

17 1 99.75 sq. ft.

A review of the facility's document titled Client Accommodation Analysis (a form that indicate the room sizes

in the facility, with room size measurement), indicated Rooms 4,5,16, and 17, did not meet the CMS (Centers for Medicare & Medicaid Services- a federal agency) requirement to ensure single bedrooms had at least 100 sq. ft per resident areas.

During an observation on 2/7/2025 at 10:20 AM, the room sizes did not affect the care and services provided to the residents when facility staff were providing care.

During an observation from 2/7/2024 at 10:25 AM, the residents residing in the Rooms 4,5.16, and 17 were observed with sufficient space for the residents to move freely inside the rooms during the care delivery and daily activities.

During a review of Resident 8's Admission Record indicated the facility originally admitted Resident 8 on 1/30/2009 and readmitted on [DATE REDACTED] with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), hypertension (high blood pressure), and anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, worry, and dread).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0912 During a review of Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/7/2025, indicated Resident 8 cognitive skills (ability to make daily decisions) was intact. The MDS Level of Harm - Potential for indicated Resident 8 required set up or clean-up assistance (helper sets up or clean up resident; resident minimal harm completes activity. Helper assists only prior to or following the activity) with eating, toileting and personal hygiene. Residents Affected - Some

During an interview on 2/7/2025 at 10:30 AM, Resident 8, stated she had enough space in her room, and

she did not have any issues with her care.

During an interview on 2/7/2025 at 10:35 AM, certified nurse assistant (CNA) 3, stated she had enough space to take care of Residents with single rooms.

During an interview on 2/7/2025 at 10:40 AM, Licensed Vocational Nurse (LVN) 2, stated she had enough space to work in single rooms, she had not heard any complaints from residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0913 Provide bedrooms that have direct access to an exit hallway.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47882 minimal harm Based on observation. interview, and record review the facility failed to ensure four of 40 resident's Residents Affected - Some bedrooms (Rooms 4, 5, 16, and 17) had direct access to the exit corridor without passing through another resident's bedroom.

This deficient practice had the potential to affect the privacy, health and safety of the residents in the room due lack of direct access to an exit during an emergency.

Findings:

During tour of the facility on 2/7/2025 at 11:05 AM, Rooms 4, 5, 16, and 17 did not have direct access into an exit corridor. Residents in rooms [ROOM NUMBERS] had to enter room [ROOM NUMBER], and rooms [ROOM NUMBERS] had to enter room [ROOM NUMBER] to get to the nearest exit corridor.

During an observation on 2/7/2025 the residents in Rooms 4, 5, 16 and 17 were ambulatory (able to walk without a device or assistance). The nursing staff had to pass through access rooms [ROOM NUMBERS] through room [ROOM NUMBER] and rooms [ROOM NUMBERS] through room [ROOM NUMBER], to provide treatments, administer medications, and assist with residents' individual routine care and activities of daily living. (ADLs, such as transferring, dressing, eating. and toileting).

During the survey period from 2/4/2025 to 2/7/2025, a room variance (a waiver for exception to the current regulations) for the residents' bedrooms received on 2/4/2025 indicated the residents' needs were accommodated and there were no adverse effects (undesired effect) to the health, safety, and welfare of the residents occupying these rooms.

During a review of Resident 46's Admission Record indicated the facility originally admitted Resident 46 on 9/28/2018 and readmitted on [DATE REDACTED] with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), hypertension (high blood pressure), and anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, worry, and dread).

During a review of Resident 46's Minimum Data Set (MDS, a Resident assessment tool), dated 1/14/2025, indicated Resident 46 cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 46 required set up or clean-up assistance (helper sets up or clean up resident; resident completes activity, helper assists only prior to or following the activity) with eating, toileting and personal hygiene.

During an interview on 2/7/2025 at 11:05 AM, Resident 46 stated he had been going in and out of his room through room [ROOM NUMBER] and he did not have any issue with it, and he felt safe.

During an interview on 2/7/2025 at 11:10 AM, Certified Nursing Assistant (CNA) 2 stated, the residents in room [ROOM NUMBER] and 17 could come out of the room by passing room [ROOM NUMBER] with no issues, no one had voiced concern about their room location.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 555755 Department of Health & Human Services Printed: 09/09/2025 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 555755 B. Wing 02/07/2025

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

Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

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 0913 During an interview on 2/7/2025 at 11:15 AM, Licensed Vocational Nurse (LVN) 2 stated residents in room [ROOM NUMBER] and 17 were ambulatory and they would walk in and out of their rooms through room Level of Harm - Potential for [ROOM NUMBER] and no issue with it. minimal harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 555755