Santa Anita Convalescent Hospital

F-F605

Findings:

During a review of Resident 124's Admission Record (AR, a document containing a resident's demographic and diagnostic information), the AR indicated Resident 124 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included Bipolar Disorder, Major Depressive Disorder (low mood or loss of pleasure or interest in activities for long periods of time), Single Episode, Difficulty Walking, and Schizophrenia (a psychiatric condition, manifested by (m/b) hallucinations/hearing voices and delusions/an unshakable belief in something that is untrue).

During a review of Resident 124's History and Physical (H&P) dated 10/24/2024, H&P indicated the residents were alert, oriented, cooperative, and currently possess the general capacity to make their own decisions and included a diagnosis of Dementia (a decline in mental ability, including memory, thinking, and reasoning, that is severe enough to interfere with daily life). Resident 124's Dementia diagnosis was not included in Resident 124's current Admission Record.

During a review of Resident 124's clinical record titled, Order Summary Report, with active orders as of 5/8/2025, included an order for Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), order dated 4/28/2025, instructions indicated to give 1 tablet by mouth at bedtime for schizophrenia m/b visual hallucinations, states that he sees people passing by but knows they are not real

During an interview on 5/8/2025 at 1:35 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 124 sometimes knows a lot. LVN 3 stated Resident 124 is confused sometimes. LVN 3 stated that Resident 124 does not hear voices, the resident can hear you but may not know what you are saying.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0657 During a concurrent telephone interview and review of clinical records on 5/8/2025 at 1:47 PM, with Psychiatrist (MD) 1 in the presence of LVN 3, Resident 124's clinical record titled, Psychiatric Progress Note, Level of Harm - Minimal harm or dated 12/8/2024 was reviewed. MD 1 stated he could not find evidence that Resident 124 has schizophrenia, potential for actual harm and he (MD 1) gave a diagnosis of major depressive disorder. MD 1 stated Resident 124 may be depressed and have some psychiatric features. MD 1 stated it is difficult to make a diagnosis of schizophrenia when a Residents Affected - Few patient (resident) is old. MD 1 stated the facility should provide NPI intervention to Resident 124, that may include redirecting the resident, comforting the resident. MD 1 stated Resident 124's behaviors are related to residents' diagnoses of dementia (a decline in mental ability, including memory, thinking, and reasoning, that is severe enough to interfere with daily life), depression (feelings of sadness and loss of interest or pleasure

in activities), confusion, agitation, and anxiety.

During a concurrent interview and record review on 5/8/2025, at 4:41 PM, with Director of Nursing (DON), Resident 124's medical record was reviewed. DON verified Resident 124 care plan for the use of Seroquel for schizophrenia for fearful posturing, dated 4/8/2025 was not reviewed and updated. DON stated there was no revised care plan or nonpharmacological interventions (NPI, treatments or strategies that aim to improve health or manage conditions without using medications, focusing instead on physical, psychological, or behavioral approaches) for Resident 124 for the use of Seroquel.

During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management in Residents with Dementia, revision dated 11/2017, indicated,

Nursing Responsibility .implements and updates the care plan as indicated . Interdisciplinary Team (IDT) Responsibility - The care plan will reflect an individualized team approach emphasizing person-centered interventions with measurable goals, timetables and specific interventions for the management of behavioral and psychological symptoms . The resident's Care Plan will include the reason(s) for the drug and describe

the behaviors the drug was prescribed to treat. The Care Plan will include the problem/symptoms the resident is experiencing, goals for the resident, a sticker or note describing the side effects of the drug, non-pharmacologic interventions to help the resident cope with the problem, i.e., quiet environment, comfort items nearby, and frequent supportive visits by staff etc. The resident's response to medications is not only evaluated by the Behavior Management Team. Evaluation and consideration of the resident's medication to continue, reduce or discontinue must also take place during . Review of care plan and monthly renewal of orders

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44018 potential for actual harm Based on observation, interview, and record review, the facility failed to assist three of five sampled residents Residents Affected - Some (Residents 40, 120, and 263) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to:

1. Provide oral care to Resident 40.

This failure had the potential for Resident 40 to have dental carries, teeth and gum infections and mouth sores that could lead to hospitalization .

2. Provide Resident 120 with a communication board (a sheet of symbols, pictures or photos that residents will learn to point to, to communicate with those around them) for Resident 120 to effectively communicate his needs.

This failure had the potential for Resident 120 to not be able to effectively communicate his needs and result

in a decline in psychosocial being.

3. Keep Resident 263's fingernails clean.

This failure had the potential for Resident 263 for skin injury, infection, and scarring.

Findings:

1. During a review of Resident 40's Admission Record, the Admission Record indicated that Resident 40 was originally admitted to the facility on [DATE REDACTED] with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level), and depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how

they act).

During a review of Resident 40's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 2/23/2025, the MDS indicated that Resident 40's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision making was impaired. The MDS indicated Resident 40 required total dependence (full staff performance) on staff for oral hygiene, toilet hygiene, and personal hygiene.

During a review of Resident 40's Care Plan, initiated on 11/29/202, the Care Plan indicated resident has an ADL (activity daily living) self-care performance deficit related to aging process, dementia, limited mobility, lack of coordination, and abnormal posture. Staff interventions included to provide oral care daily and PRN (as needed).

During an observation on 5/5/2025 at 8:50 AM, in Resident 40's room. Resident 40 was observed lying in bed. Resident 40's lips were observed dry, scaly, and cracked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0677 During an interview and observation on 5/6/2025 at 1:38 PM, in the Resident 40's room with Registered Nurse 1 (RN 1), RN 1 stated Resident 40's lips were dry. RN stated it could be from poor oral hygiene. RN 1 Level of Harm - Minimal harm or stated Certified Nurse Assistants (unidentified) should provide oral care daily and after meals. potential for actual harm

During an interview on 5/7/2025 at 11:13 AM, in the Resident 40's room, with Quality Assurance Nurse 1 Residents Affected - Some (QAN 1), QAN 1 stated Resident 40's lips were very dry and cracked. QAN 1 stated Resident 40 always had his mouth open which could cause his lips to be drier than normal usual. QAN 1 stated she would apply lip moisturizer. QAN 1 stated, Maintaining good oral care was as important as resident's physical health. Dry lips could become inflamed as a result of bacteria entering the cracks in the skin of the lips.

During a review of facility's policy and procedures (P&P) titled, Grooming revised 6/1/2017, the P&P indicated that the facility will work with residents to improve their ability to groom him/herself to promote independence, hygiene, comfort, self-esteem and dignity by teaching the resident to groom him/herself with

the use of assistive devices or techniques and with the appropriate types and amount of assistance. The P&P also indicated that self-grooming activities include combing or brushing hair, shaving, applying make-up, brushing teeth or dentures and taking care of fingernails and toenails.

2. During a review of Resident 120's Admission Record, the Admission Record indicated Resident 120 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with dysphagia (difficulty swallowing) following cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area), emphysema (lung condition that causes shortness of breath), and adult failure to thrive (unintentional weight loss, a decline in functional abilities, and an overall decline in health status.)

During a review of Resident 120's MDS, dated [DATE REDACTED], the MDS indicated Resident 120's cognitive skill for daily decision making was severely impaired. The MDS indicated Resident 120 required substantial/maximal assistance (helper does more than half the effort) from staff for shower/bathe self, putting on/taking off footwear, and personal hygiene.

During a review of Resident 120's Care Plan indicated resident has an impaired communication problem related to language barrier, initiated on 7/29/2024, Staff interventions indicated for Resident 120 to be able to communicate by writing, using communication board, gestures, sign language, and translator.

During an observation on 5/5/2025 at 12:20 PM, in Resident 120's room, Resident 120 was observed making hand gestures toward Certified Nursing Assistant 8 (CNA 8). CNA 8 was observed attempting to communicate with Resident 120 by asking what he needed.

During an interview on 5/5/2025 at 12:22 PM, in Resident 120's room with CNA 8, CNA 8 stated she did not understand exactly what Resident 120 wanted. CNA 8 stated Resident 120 was able to communicate with

the staff with a communication board (a sheet of symbols, pictures or photos that one can use by point to, to communicate with those around them), however, the communication board was not available in the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0677 During an interview on 5/7/2025 at 3:46 PM, with QAN 1, QAN 1 stated the facility provided communication boards to residents who have any language barrier. The communication board should be available in the Level of Harm - Minimal harm or room and accessible for all residents and staff. QAN 1 stated that the communication board had pictures and potential for actual harm the resident's primary language, so the resident could pinpoint the picture to communicate his/her needs to

the staff. Residents Affected - Some 47362

3. During a review of Resident 263's Admission Record, the Admission Record indicated Resident 263 was initially admitted to the facility on [DATE REDACTED] with diagnosis which included sepsis (a life-threatening blood infection), dysphagia (swallowing difficulties), and muscle weakness.

During a review of Resident 263's MDS, dated [DATE REDACTED], the MDS indicated Resident 263's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 263 required substantial maximal assistance (helper does more than half the effort) on oral hygiene, toilet hygiene, and personal hygiene.

During a concurrent observation and interview on 5/5/2025 at 10:56 AM with CNA11, CNA 11 stated Resident 263's fingernails were observed dirty and crusted (having or forming a hard top layer or covering).

During a concurrent observation and interview on 5/8/2025 at 5:17 PM with the Licensed Vocational Nurse 16 (LVN 16), LVN 16 stated Resident (Resident 263)'s fingernails were disgusting, with black fecal matter (the material in a bowel movement. Feces are made up of undigested food, bacteria, mucus, and cells from

the lining of the intestines. Also called stool) on the nail bed. LVN 16 also stated these can possibly cause infection, sickness-like diarrhea and stomachache. LVN 16 also stated the facility needs to maintain residents' self-worth, dignity and self-esteem.

During a review of facility's Policy and Procedure (P&P) titled, Grooming Care of the fingernails and toenails, dated 6/1/2017, the P&P indicated nail care is given to clean and keep the nails trimmed.

During a review of facility's P&P titled, Resident Rights, revised date 10/1/2017, indicated purpose was to promote and protect the rights of all residents at the facility. P&P indicated all residents have right to dignified existence, self-determination. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. P&P also indicated employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

During a review of facility's P&P titled, Infection Prevention and Control Program, revised date 10/24/2022,

the P&P indicated its purpose is to ensure the facility established and maintains an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48903 potential for actual harm Based on observation, interview, and record review, the facility failed to set the low air loss mattress (LALM, Residents Affected - Few pressure relieving mattress that operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) at the correct setting for one (1) of four (4) sampled resident's (Resident 112) in accordance with the facility's policy and procedure (P&P) titled, Pressure Ulcer Prevention and physician's order.

This deficient practice had the potential to result in Resident 112 developing pressure ulcers.

Findings:

During a review of Resident 112's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included muscle weakness, sepsis (a life-threatening blood infection) and chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Resident 112's Minimum Data Set (MDS, resident assessment screening tool), dated 3/9/2025, the MDS indicated the resident had severe impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. Resident 112 was dependent (staff does all the effort in tasks, resident does no effort in task, assistance of two or more helpers is sometimes required to complete a task) on staff for toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. Resident 112 required supervision (helper provides verbal cues or touching assistance) for upper body dressing. Resident 112 required set up or clean up assistance (helper sets up or cleans up) for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 51 was at risk of developing pressure ulcers.

During a review of Resident 112's Order Summary Report, dated 1/26/2025, the order summary indicated, Resident 112 was ordered a LALM, and it was to be set based on Resident 112's weight.

During a review of Resident 112's Weight Summary, dated 4/7/2025, the Weight Summary indicated Resident 112 weighed 82 lbs (pounds; unit of measurement for weight).

During a review of Resident 112's Care Plan titled, The resident has potential for pressure ulcer development related to immobility, dated 9/26/2024, the care plan indicated staff interventions were to administer treatments as ordered and monitor for effectiveness.

During an observation on 5/5/2025 at 10:33 AM, Resident 112's LALM was observed to be set at 50 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0686 During a concurrent record review and interview on 5/5/2025 at 10:35 AM with Licensed Vocational Nurse 5 (LVN 5), Resident 112's weight summary was reviewed. The weight summary indicated Resident 112 Level of Harm - Minimal harm or weighed 82 lbs. on 4/7/2025. LVN 5 stated, Resident [Resident 112] weighed 82 lbs on 4/7/2025 and the potential for actual harm LALM is currently set at 50 lbs. The purpose of the LALM is to alternate the air pressure and prevent bed sores. If it's not set at the correct weight setting it's not preventing bed sores. Residents Affected - Few

During a concurrent interview and record review on 5/8/2025 at 4:00 PM with the Director of Nursing (DON),

the facility's P&P titled, Pressure Ulcer Prevention, dated 6/1/2017 was reviewed. The P&P indicated:

1. Purpose: to identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications.

2. The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development.

The DON stated that if the LALM is set at a lower setting than the resident's weight it can put the resident at risk for skin breakdown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44018

Residents Affected - Few Based on interviews and record reviews, the facility failed to lock the casters (wheels that are attached to the bottom of a furniture to make them easier to move) of the bed for one of seven sampled residents (Resident 190), who had a history of fall accidents.

This deficient practice has the potential for Resident 190 to have a repeated fall and sustain serious injury.

Findings:

During a review of Resident 190's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level), other abnormalities of gait and mobility, and muscle weakness.

During a review of Resident 190's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2025,

the MDS indicated Resident 190 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 190 was assessed to require partial/moderate assistance (helper does less than half the effort) with sitting to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated Resident 190 was assessed having two fall incidents with no injury and one fall incident since admission/entry or prior assessment.

During a review of Resident 190's Fall Risk (Morse) Assessment (a widely used assessment tool that helps healthcare professionals predict a resident's risk of falling in healthcare settings like hospitals and long-term care facilities), dated 3/11/2025, the Fall Risk Assessment indicated Resident 190 was high risk for falls.

During an observation on 5/5/2025 at 8:35 AM, in Resident 190's room. Resident 190 was observed attempting to get herself out of bed by holding onto the side rail and bedside table to stand up. Resident 190's bed was observed moving and the bed casters were left unlocked. Resident 190 stated, I don't know why the bed is moving.

During an observation and interview on 5/5/2025 at 8:40 AM, in Resident 190's room with Assistant Director of Nursing (ADON), ADON confirmed the bed casters were left unlocked causing the bed to move around. ADON stated failure to properly lock the casters could lead to Resident 190 sustaining another fall and getting into a serious injury.

During a review of the manufacturer's Owner Manual, the Owner Manual indicated that involuntary bed movement may take place if the floor lock or bed casters are left unlocked. Involuntary bed movement may lead to property damage or resident injury. Never leave a bed unattended while the floor lock is disengaged.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0689 During a review of facility's policy and procedure (P&P), titled Fall Management Program, revised dated 6/1/2017, the P&P indicated the facility to provide the highest quality care in the safest environment for the Level of Harm - Minimal harm or residents residing in the facility. The P&P indicated to place bed in lowest position with brake locked. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44018

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of five sampled residents (Resident 40 and 5) by failing to ensure:

1. Resident 40's head of bed (HOB) was elevated to an angle of 30 to 45 degrees while the resident was receiving G-tube feeding (a liquid food mixture provided through the G-tube).

This deficient practice had the potential for Resident 40 to aspirate (when something swallowed enters the lungs) which could lead to pneumonia (infection that inflames air sacs in one or both lungs) and/or choke.

2. To maintain a clean [NAME] Valve (a stopcock-like device, which allows the health care worker to access enteral systems without breaking open the lines) for G-tube.

This deficient practice had the potential to result in complications including infections and stomach discomfort.

Findings:

1. During a review of Resident 40's Admission Record, the Admission Record indicated that Resident 40 was originally admitted to the facility on [DATE REDACTED] with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level), and depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how

they act).

During a review of Resident 40's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 2/23/2025, the MDS indicated Resident 40's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were impaired. The MDS indicated Resident 40 required total dependence (full staff performance) on staff for oral hygiene, toilet hygiene, and personal hygiene. The MDS indicated Resident 40 was on feeding tube.

During a review of Resident 40's Physician Oder, order date 10/7/24, the Physician Order indicated to elevate the HOB 30 to 45 degrees at all times during feedings and for at least 30 to 40 minutes after the feeding is stopped.

During a review of Resident 40's Care Plan, initiated on 5/7/2005, the Care Plan indicated Resident 40 required tube feeding for his nutritional needs. It also indicated Resident 40 was at risk for aspiration. Staff interventions included for Resident 40's HOB to be elevated to 45 degrees during and 30 minutes after tube feed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0693 During an observation on 5/5/2025 at 8:50 AM, in Resident 40's room. Resident 40 was observed lying in bed with the HOB flat. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 5/8/22 at 3:39 PM, in Resident 40's room, with a Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 40 was receiving G-tube feeding and the HOB was not elevated to Residents Affected - Few Semi-fowler's (supine posture where the resident lies on the back with head and upper body elevated between 30 to 45 degrees) position per physician order.

During an observation and interview on 11/2/22 at 3:41 PM, in Resident 40's room, with Quality of Assurance Nurse 1 (QAN 1), QAN 1 stated Resident 40's HOB should be raised at least 30 to 45 degrees while the resident was receiving G-tube feeding. QAN1 stated Resident 40 was at risk for aspiration if the HOB was too low.

During a review of the facility's Policy and Procedure (P&P) titled, Bolus Feeding, revised 6/1/2017, the P&P indicated staff were to leave the resident in semi-Fowler's position during tube feeding and at least one hour

after feeding.

47362

2. During a review of Resident 5's Admission Record, the Admission Record indicated the facility originally admitted Resident 5 on 2/10/2023 and was readmitted on [DATE REDACTED] with diagnoses which included dysphagia (swallowing difficulties), diabetes mellitus (condition that causes blood sugar to rise), and anemia (condition

in which the body does not have enough healthy red blood cells).

During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 3/24/2025, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 5 required dependent (helper does all the effort) with toilet hygiene, shower/bathe self, personal hygiene. The MDS also indicated Resident 5's nutritional approach included a feeding tube while a resident in the facility.

During a record review of Resident 5's Order Summary Report, the Order Summary Report, dated 5/7/2025, indicated for the following enteral feed (delivering nutrition and calories through the gastrointestinal [GI] tract) order dated 3/17/2025:

a. Order as needed if soiled or dislodge

b. Every day shift G-tube site cleans with normal saline (NS, fluid and electrolyte replenisher used as a source of water and electrolytes) cover with dry dressing.

c. Every shift check tube placement before initiation of formula, medication administration and flushing tube.

d. Every shift Nepro 1.8 at 55 Cubic Centimeter/hour (cc/hr., measure of volume flow rate) for 20 hours per G-tube via dual pump . date ordered 4/2/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0693 During a record review of Resident 5's Care Plan, dated 4/3/2025, the Care Plan indicated a goal for the Resident's insertion site will be free of signs and symptoms of infection through the review date. Resident 5's Level of Harm - Minimal harm or care plan interventions included to inspect the skin around the stoma for signs and symptoms of infection potential for actual harm and inspect the tube for inward or outward migration and observed for leakage.

Residents Affected - Few During a concurrent observation in Resident 5's room and interview with respiratory therapist (RT1) on 5/5/2025 at 10:07AM, the RT1 stated Resident 5's the [NAME] Valve was dirty with black dry discoloration.

During an interview on 5/8/2025 at 2:00 PM with Registered Nurse 1 (RN1), RN 1 stated, A dirty [NAME] Valve was not acceptable, it is infection control.

During a concurrent interview and record review on 5/8/2025 at 5:04 PM with licensed vocational nurse 16 (LVN16), LVN 16 stated the facility does not have Policy and Procedure (P&P) regarding maintaining [NAME] Valve. LVN 16 also stated the facility is supposed to create one.

During a review of facility's P&P titled, Infection Prevention and Control Program, revised date 10/24/2022,

the P&P indicated the purpose was to ensure the facility established and maintains an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 potential for actual harm Based on interview, and record review, the facility failed to ensure one of three sampled resident (Resident Residents Affected - Few 74), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right upper arm arteriovenous shunt (AV shunt, direct connection between an artery and a vein, bypassing the capillaries [tiny blood vessels that deliver nutrients and oxygen to cells throughout the body], which can be created surgically for various reasons including hemodialysis access) vascular (relating to vessels that carry blood or other liquids in a person's body) access in accordance with the facility policy.

This deficient practice had the potential for Resident 74 to suffer from complications such as bleeding or infection and potential for unnoticed or missed excessive bleeding.

Findings:

During a review of Resident 74's Admission Record, the Admission Record indicated Resident 74 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis, and anemia (a condition where the body does not have enough healthy red blood cells).

During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 74's cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 74 required partial/moderate assistance (helper does less than half the effort) with eating. The MDS indicated Resident 74 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 74 was dependent (helper does all the effort) with toileting and showering. The MDS also indicated that Resident 182 was receiving hemodialysis.

During a review of Resident 74's Order Summary Report, dated 5/7/2025, the Order Summary Report indicated hemodialysis every Monday, Wednesday, and Friday, ordered on 1/16/2025.

During a review of Resident 74's Order Summary Report, dated 5/7/2025, the Order Summary Report indicated hemodialysis access site of right upper arm av shunt, check access site for signs and symptoms of infection (growth of germs in the body), and if bruit (swooshing, an abnormal sound) and thrill (vibration that can be felt) is present, ordered on 2/16/2025.

During a concurrent record review and interview on 5/7/2025 at 12:05 PM, with Assistant Director of Nursing 2 (ADON 2), Resident 74's nurses dialysis communication records, dated 4/14/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/23/2025, 4/25/2025, 4/28/2025, 4/30/2025, 5/2/2025 and 5/5/2025 were reviewed. The ADON 2 verified these dates have incomplete dialysis access site assessment from dialysis center. The ADON 2 stated that having no documentation might cause confusion when delivering care to Resident 74.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0698 During a concurrent record review and interview on 5/8/2025 at 4:20 PM, with ADON 3, Resident 74's nurses dialysis communication records, dated 4/14/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/23/2025, 4/25/2025, Level of Harm - Minimal harm or 4/28/2025, 4/30/2025, 5/2/2025 and 5/5/2025 were reviewed. The ADON 3 verified these dates have potential for actual harm incomplete dialysis access site assessment from dialysis center. The ADON 3 verified these were incomplete because some of the questions were not answered and left blank. The ADON 3 stated the receiving Residents Affected - Few Licensed Vocational Nurse or Registered Nurse (RN) should have called the dialysis center if Dialysis communication record was incomplete. The ADON 3 stated, it was important to properly assess residents, document accurately, and complete the Dialysis communication record to make sure that resident will receive the proper care.

During a review of the facility's Policy and Procedure (P&P) titled Dialysis Care, revised in 11/1/2017, the P&P indicated the Nursing Staff, Dialysis Provider Staff, and the Attending Physician (Dialysis Staff) will collaborate on a regular basis concerning the resident's care as follows:

The Dialysis Provider will communicate in writing to the Facility:

a. The resident's current vital signs;

b. Pre and post dialysis weight; and

c. Any problems encountered while the resident was at the Dialysis Provider.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087

Residents Affected - Few Based on observation, interview, and record review the facility failed to provide necessary behavioral health care and services by failing to implement the care plan to provide a one to one sitter on 5/6/2025 for one of two sampled residents (Resident 270) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), and with suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide [death caused by self-directed injurious behavior with the intent to die as a result of the behavior]).

This deficient practice had the potential to cause harm/injury to Resident 270.

Findings:

During a review of Resident 207's Admission Record, the Admission Record indicated Resident 207 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included depression, End Stage Renal Disease (ESRD- irreversible kidney failure), and gastrostomy (a surgical opening fitted with

a device to allow feedings to be administered directly to the stomach common for people with swallowing).

During a review of Resident 270's Minimum Data Set (MDS- a resident assessment tool) dated 2/26/2025,

the MDS indicated Resident 270's cognitive (ability to think and reason) skills for daily decision making was modified independence (some difficulty in new situations only). The MDS also indicated Resident 270 needed partial moderate assistance (helper does less than half of the effort: helper lifts, holds, or supports trunk limb, but provides less than half of the effort) with oral hygiene and upper body dressing. The MDS also indicated Resident 270 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS further indicated Resident 270 had diagnoses of depression.

During a review of Resident 1's care plan related to having suicidal ideation, initiated on 5/4/2025, the care plan intervention included the following:

One to one sitter

Coordinate with a multidisciplinary team (a group of professionals from different disciplines who work together to achieve a common goal).

During a review of Resident 270's Nurse Progress notes, dated 5/4/2025, timed 11:18 PM, the Nurse Progress notes indicated Resident was stating that he wanted to die and didn't want any medication to be given to him and he would rather die. The resident stated, Let me die, I don't want any medication.

During a review of Resident 270's Order Summary Report dated 5/7/2025, timed 4:06 PM, the Order Summary Report indicated an order of one-to-one sitter for 72 hours, with order date of 5/4/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 a review of Resident 270's Nurse's Notes, dated 5/6/2025, timed at 2:52 AM, the Nurse's Notes indicated Resident on monitoring for suicidal ideation. No sitter on night shift (11 PM - 7:30 AM). Level of Harm - Minimal harm or potential for actual harm During an observation on 5/6/2025 at 5:37 AM, in Resident 270's room, Resident 270 was sleeping. There was no sitter or staff in Resident 270's room. Residents Affected - Few

During a concurrent observation and interview on 5/6/2025 at 5:48 AM, in the hallway outside Resident 270's room, Certified Nursing Assistant 2 (CNA 2) verified that there was no sitter in Resident 270's room. CNA 2 stated she did not see a staff member sitting in Resident 270's room throughout the night.

During an interview on 5/6/2025 at 5:55 AM with CNA 9, CNA 9 stated he did not see any staff member who sat in Resident 270's room throughout the night shift. CNA 9 added he did not know Resident 270 need to have a sitter.

During an observation on 5/6/2025 at 6:14 AM, in Resident 270's room, there was no sitter observed.

During an interview on 5/6/2025 at 6:16 AM with LVN 1, LVN 1 stated Resident 207 did not have a sitter since 11 PM. LVN 1 stated the unit has only 2 assigned CNAs, and there was no extra staff to sit with Resident 207. LVN 1 stated she was aware that Resident 207 was on monitoring for suicidal ideation, but

she did not inform the RN supervisor that there was no assigned staff to sit with Resident 207 at the beginning of their shift last night at 11 PM.

During an interview on 5/8/2025 at 5:34 PM with the Director of staff services (DSD), the DSD is unable to provide written evidence of staff assignment to sit with Resident 207 from 5/5/2025 11 PM to 5/6/2025 7 AM.

The DSD stated having a sitter to watch a resident who has suicidal ideation was important to prevent any accidents from happening because the resident might do something to hurt him/herself when there is no staff watching.

During an interview on 5/8/2025 at 5:49 PM with the Director of Nursing (DON), the DON stated Resident 207 has an order for sitter on 5/4/2025 due to suicidal ideation. The DON stated he did not know why there was no sitter assigned to Resident 207 on 5/6/2025.

During a review of Facility's Policy and Procedure (P&P), titled Suicide Prevention, revised on 6/1/2017, the P&P's purpose indicated to provide safety measures and immediate short-term treatments to residents who presents a suicide risk after admission to the facility. The procedure indicated the following:

All facility staff members are obligated to report suicidal statements or other indicators of possible suicidal ideation to their immediate supervisor.

If a resident mentions suicidal ideations at any time, the resident shall be assigned one to one supervision until the assessment is completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31333

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and accurate provision of medication for four of four sampled residents (Resident 15, 32, 238, and 299) observed by failing to:

1. and 2. Identify Residents 299 and Resident 32 prior to administering medications.

3. and 4. Ensure physician orders which include parameter to determine when to administer blood pressure medication matched the prescription labels for Resident 238 and Resident 15.

These deficient practices increased the potential for inaccurate and unsafe medication administration to meet

the needs of each resident (Resident 15, 32, 238, and 299).

Findings:

1. During a concurrent interview and medication pass observation on 5/6/2025 between 8:32 AM to 8:58 AM, with Licensed Vocational Nurse (LVN) 4 on Unit 200 at Medication Cart 2. LVN 4 stated Resident 299 was alert and oriented times 4 (is alert and oriented to person, place, time and event). LVN 4 was prepared Resident 299's morning medications, entered the resident's room and called the resident by name, then administered the medications to Resident 299. LVN 4 was not observed using identifiers to verify the resident's identity prior to administering the medications to Resident 299. The following medications were observed prepared and administered to Resident 299:

i. Baclofen (treat muscle stiffness) 5 milligrams (mg - unit of measure by weight), three tablets (15 mg)

ii. Oxybutynin (treat overactive bladder) 5 mg, one half tablet (2.5 mg)

iii. Nitrofurantoin (antibiotic to treat infection) 100 mg, one tablet

iv. Magnesium Oxide (mineral supplement) 400 mg, one tablet

v. Docusate Sodium (stool softener) 100 mg, one tablet

vi. Omega 3 (Fish Oil, supplement) 1000 mg, one capsule

vii. Multivitamin with Minerals (supplement), one tablet

viii. Vitamin C (vitamin supplement) 500 mg, one tablet

ix. Acidophilus (Probiotic), one capsule

During an interview on 5/6/2025 at 9:02 AM with Resident 299, Resident 299 stated the licensed nurse did not ask her name.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0755 During an interview on 5/6/2025 at 9:03 AM with LVN 4, LVN 4 stated all residents wear an identification bracelet with the resident's name. LVN 4 stated she did not look at Resident 299's identification bracelet to Level of Harm - Minimal harm or identify the resident before giving the medications. potential for actual harm 2. During a concurrent interview and medication pass observation on 5/6/2025 between 10:02 AM to 10:07 Residents Affected - Some AM, with LVN 6 on Unit 600 at the Medication Cart. Resident 32 was observed in a wheelchair in the hallway next to the medication cart. LVN 6 stated Resident 32 was asking for medications. LVN 6 prepared and administered two medications to Resident 32. LVN 6 stated Resident 32's name and was not observed verifying Resident 32's identity prior to administering the medications. The following medications were observed prepared and administered to Resident 32:

i. Clonazepam (a controlled medication [potential for abuse and dependence], used to relieve sudden, unexpected attacks of extreme fear and worry) 1 mg, one tablet

ii. Docusate Sodium 250 mg, one capsule

During an interview on 5/6/2025 at 10:35 AM with LVN 6, LVN 6 stated, for Resident 32, I did not look at his (Resident 32) bracelet (identification bracelet) because he just came up at the medication cart and asked for his medications.

During an interview on 5/6/2025 at 2:47 PM, with Director of Nursing (DON), the DON stated that licensed nurses must verify the resident's identity prior to medication administration by, asking the resident to state their name if the resident is alert, or

comparing the picture in the facility computer system to the resident and asking the resident to state their name, or

looking at the identification bracelet on the resident's wrist, or verifying the resident with another facility staff that knows the resident if the resident is missing an identification bracelet. The DON stated if we are trying to identify the resident prior to medication administration, licensed nurses should be asking the resident to state their name.

During a review of the facility's Policy and Procedures (P&P) titled, Medication Administration, revision dated 6/2017, indicated, to provide practice standards for safe administration of medications for residents in the Facility Verify the resident's identity before administering the medication.

3. During a review of Resident 238's Admission Record (AR, a document containing a resident's demographic and diagnostic information), the AR indicated Resident 238 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included Atrial Fibrillation (AFib, an irregular and often very rapid heart rhythm) and Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (also known as Congestive Heart Failure [CHF],

a condition where the heart cannot pump enough blood to meet the body's needs)).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0755 During a review of Resident 238, May 2025 Order Summary, Resident 238's Order Summary included a physician order for Spironolactone Oral Tablet 25 mg, instructions indicated to give 1 (one) tablet by mouth Level of Harm - Minimal harm or one time a day (9 AM) for fluid retention. Hold for systolic blood pressure (SBP, blood pressure when the potential for actual harm heart beats, measured in millimeters mercury, mmHg) less than 110 mmHg or if the heart rate (HR, the number of times the heart beats per minute [bpm]) is less than 60 bpm, order dated 5/5/2025. Residents Affected - Some

During a concurrent interview and medication pass observation on 5/6/2025 at 9:56 AM, with LVN 5, LVN 5 stated, Resident 238's blood pressure medication Spironolactone had a physician ordered parameter to hold if SBP was less than 110 mmHg or the HR was less than 60 bpm.

During a review of Resident 238's prescription label for Spironolactone, instructions indicated, Take 1 tablet by mouth daily. Resident 238's prescription label did not include the physician's order to hold if the resident's SBP was less than 110 mmHg or HR was less than 60 bpm.

During an interview on 5/6/2025 at 9:56 AM with LVN 5, LVN 5 stated Resident 238's Spironolactone prescription label did not include a hold parameter. LVN 5 stated Resident 238's prescription label did not match with the resident's Medication Administration Record instructions or with the resident's current physician's order for use.

4. During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included Atrial Fibrillation (AFib, an irregular and often very rapid heart rhythm) and Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (also known as Congestive Heart Failure [CHF],

a condition where the heart cannot pump enough blood to meet the body's needs).

During a review of Resident 15, May 2025 Order Summary, Resident 15's Order Summary included a physician order for Amiodarone HCl Tablet 200 mg, instructions indicated to give 1 (one) tablet by mouth one time a day (9 AM) for AFib. Hold if heart rate (HR, the number of times the heart beats per minute [bpm]) is less than 60 bpm, order dated 4/16/2023.

During a concurrent interview and medication pass observation on 5/6/2025 between 10:11 AM to 10:30 AM, with LVN 6, LVN 6 prepared morning medications for Resident 15 that include Amiodarone 200 mg, one tablet. LVN 6 stated there was a parameter for Resident 15's blood pressure medication, Amiodarone to hold if the HR is less than 60.

During a review of Resident 15 prescription label for Amiodarone, instructions indicated, Take 1 tablet by mouth daily. Resident 15's prescription label did not include the physician's order to hold if the resident's HR was less than 60 bpm.

During an interview on 5/6/2025 at 2:47 PM with the DON, the DON stated having the prescription label on

the medication pack should match with the current physician's order and MAR to prevent medication errors and make sure there are no medication discrepancies.

During a review of the facility's P&P titled Medication Administration, revision dated 6/2017, indicated, The Rule of 3 - The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0755 Compare the Licensed Practitioner's prescription/order with the MAR (first check).

Level of Harm - Minimal harm or Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second potential for actual harm check).

Residents Affected - Some Compare the pharmacy label and MAR (third check).

Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31333 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure it was free of medication Residents Affected - Some error rate of five percent (5%) or greater, as evidenced by the identification of two medication errors out of 33 opportunities (observations during medication administration) for error, to yield a cumulative error rate of 6.06 % for two of four residents (Resident 32 and Resident 15) observed during the medication administration:

1. Facility failed to ensure the correct medication dose and form of docusate sodium was administered to Resident 32.

2. For Resident 15, facility licensed nurse did not check heart rate (HR, the number of times the heart beats per minute [bpm]) prior to administration of Amiodarone 200 mg as ordered.

These deficient practices had the potential to result in harm to Resident 32 and Resident 15, by not administering medication as prescribed by the physician in order to meet resident's individual medication and therapeutic needs (the specific types of treatments or interventions that are necessary to address a person's medical condition or improve their overall well-being).

Findings:

1. During a review of Resident 32's Admission Record (AR, a document containing a resident's demographic and diagnostic information), the AR indicated Resident 32 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included Intervertebral Disc Displacement, Lumbar Region (a condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine (vertebrae), causing pain in the back or neck and frequently in the legs and arms), low back pain, and anxiety (a feeling of worry, nervousness, or fear about something that might happen).

During a review of Resident 32's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 4/11/2025, the MDS indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact.

During a review of Resident 32, May 2025 Order Summary, Resident 32's Order Summary included the following physician orders:

a. Docusate Sodium Oral Tablet 100 mg, order dated 4/8/2025, instructions indicated to give 1 tablet by mouth four times a day (9 AM, 1 PM, 5 PM, and 9 PM) for bowel management, hold for loose stools.

b. Clonazepam Oral Tablet 1 mg, order dated 4/24/2025, instructions indicated to give 1 tablet by mouth every 8 (eight) hours as needed for anxiety manifested by (m/b) verbalization of feeling nervous for 14 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 and observation of medication administration on 5/6/2025, at 10:02 AM, a resident was observed in a wheelchair in the hallway next to the medication cart (MedCart) on Unit 600. Level of Harm - Minimal harm or Licensed Vocational Nurse 6 (LVN 6) stated Resident 32 was asking for his medication. LVN 6 prepared two potential for actual harm medications, Clonazepam 1 milligrams (mg, unit of measure by weight) one tablet and Docusate Sodium 250 mg, one capsule. LVN 6 stated the resident's name (Resident 32) and administered the two medications. Residents Affected - Some LVN 6 was not observed asking the resident to state his name, date of birth, or looked at the resident's identification bracelet prior to administering the medication to Resident 32.

During an interview on 5/6/2025 at 10:35 AM, with LVN 6, LVN 6 stated, I did not look at Resident 32's identification bracelet because he just came up to me at the medication cart and asked for his medications.

During a concurrent interview and record review on 5/6/2025 at 2:05 PM, with LVN 6, Resident 32's Order Summary was reviewed. LVN 6 stated Resident 32 does not have an order for Docusate Sodium 250 mg capsule. LVN 6 stated that was her mistake. LVN 6 stated Resident 32's order was for Docusate Sodium 100 mg tablet with orders to administer four times a day.

During an interview on 5/6/2025 at 2:47 PM, with the Director of Nursing (DON), the DON stated that licensed nurses must identify residents prior to medication administration. The DON stated a positive identification of the resident would be by comparing the resident to the resident's picture in the facility's computer system, looking at the resident's identification bracelet/band, or having an alert and oriented resident to state their name.

2. During a review of Resident 15's AR, the AR indicated Resident 32 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included Atrial Fibrillation (AFib, an irregular and often very rapid heart rhythm) and Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (also known as Congestive Heart Failure [CHF],

a condition where the heart cannot pump enough blood to meet the body's needs)).

During a review of Resident 15's MDS dated [DATE REDACTED], the MDS indicated the resident's cognition was intact.

During a review of Resident 15's Care Plan for:

a. CHF last reviewed 3/26/2025 indicated to administer Amiodarone 200 mg daily as ordered .Monitor vital signs (reflect essential body functions, including the heartbeat, breathing rate, temperature, and blood pressure). Notify MD of significant abnormalities .Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of Congestive Heart Failure .increase heart rate (Tachycardia), lethargy and disorientation.

b. Altered cardiovascular status r/t (related to) AFib last reviewed 3/26/2025 indicated to administer cardiac medication (amiodarone) as ordered . Monitor vital signs. Notify MD of significant abnormalities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 review of Resident 15's May 2025 Order Summary, Resident 15's Order Summary included a physician order for Amiodarone HCl Tablet 200 mg, instructions indicated to give 1 (one) tablet by mouth one Level of Harm - Minimal harm or time a day (9 AM) for AFib. Hold if HR is less than 60, order dated 4/16/2023. potential for actual harm

During a concurrent interview and observation of medication administration on 5/6/2025, at 10:11 AM, with Residents Affected - Some LVN 6, LVN 6 prepared Resident 15's medications that included Amiodarone 200 mg. LVN 6 entered Resident 15's room, stated the resident's name and administered the medications. LVN 6 was not observed checking the resident's HR prior to administering to the resident Amiodarone for AFib. LVN 6 was not observed explaining each medication to Resident 15 prior to medication administration.

During an interview on 5/6/2025 at 10:31 AM, with LVN 6, LVN 6 stated, she checked Resident 15's blood pressure and HR in the morning at 8:45 AM, on 5/6/2025 and the BP was low 94/76 and the HR was 62.

During a follow-up interview on 5/6/2025 at 2:12 PM, with LVN 6, LVN 6 stated she checked Resident 15's BP and HR at 8:45 AM, today, 5/6/2025 but did not document the results of the BP and HR until 10:15 AM on 5/6/2025. LVN 6 stated she should have documented the vitals (BP and HR) right away for Resident 15 after checking them this morning (5/6/2025). LVN 6 stated she should have checked Resident 15's HR before giving the medication Amiodarone because there was an ordered parameter to determine when to give or hold the medication.

During an interview on 5/6/2025, at 2:47 PM, with the Director of Nursing (DON), the DON stated the best practice is for the licensed nurses to check the residents' vitals prior to medication administration when there is an ordered parameter to check vital signs. DON stated for accuracy of documentation of vital signs when it comes to medication administration the window to document vital signs opens in the facility's computer system when the licensed nurses are administering medication. DON stated the licensed nurse will receive a prompt in the facility's computer system to document vitals when the process of medication administration is completed.

During a review of the facility's Policy and Procedures (P&P) titled Medication Administration, revision dated 6/2017, the P&P indicated, No medication will be used for any resident other than the resident for whom it was prescribed . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (i.e., BP, pulse, finger stick blood glucose monitoring etc.) . Nursing Staff will keep in mind the seven rights of medication when administering medication:

a. The right medication

b. The right amount

c. The right resident .

The resident's MAR (Medication Administration Record) will be reviewed for allergies and/ or special considerations for administration including .Vital sign parameters . as appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47362 Residents Affected - Some Based on observation, interview, and record review, the facility failed to:

1. Ensure one of four (4) medication carts (med cart 1 - [Unit A medication cart ] a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) was kept locked when unattended to prevent unauthorized access in accordance with the facility's P&P titled Medication Storage in the Facility.

This deficient practice had the potential to result in unauthorized access of medications by residents, visitors and staff and predisposing them to possible medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use of medications, adverse reactions (any unexpected or dangerous reaction to a drug), and drug-to-drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement).

2. Ensure medications and biologicals were properly stored and labeled for six of six current and discharged residents (Resident 174, 219, 231, 483, and 484):

a. Remove a discharged resident (Resident 484) antibiotic (medication to treat infection) from Unit 700 med cart and accurately account for each dose until destroyed.

b. Ensure a Lantus SoloStar (a prefilled insulin pen containing the long-acting insulin, used to manage blood sugar levels) insulin pen labeled for Resident 483 was refrigerated until opened and not stored at room temperature inside of Unit 300 med cart 2.

c. Ensure discontinued controlled medication (medications with a high abuse potential), noncontrolled medications, and bedhold medications were removed from Unit 300 med cart 1 for Residents 174 and Unit 400 med cart 1 for Residents 211, 231, and 219.

These deficient practices had the potential of delayed care, exposing residents to deteriorated (less effective or potentially harmful) or contaminated medications, medication errors, and increased risk for drug loss or diversion (when prescription medicines are obtained or used illegally).

Findings:

During a concurrent observation and interview on [DATE REDACTED] at 3:52 PM with the administrator (ADMIN) in Unit A, med cart 1 was unlocked and no facility staff/ licesnsed nurse near the med cart 1. ADMIN stated med cart 1 was unlocked, and that the medication cart was left unattended.

During an interview on [DATE REDACTED] at 3:53 PM with License Vocational Nurse (LVN), LVN 15 stated, LVN 15 forgot to lock the med cart 1 when she left Unit A to attend to a resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 During an interview on [DATE REDACTED] at 4:50 PM with the Registered Nurse (RN) 3, RN 3 stated medication carts were supposed to be locked all the time, when unattended for safety reasons. RN 3 stated, confused and Level of Harm - Minimal harm or wandering residents can get assess to medications not intended for them. RN 3 stated it can cause harm potential for actual harm that can lead to complications.

Residents Affected - Some During an interview on [DATE REDACTED] at 5:35 PM with LVN 16, LVN 16 stated only the nurse in charge of the medication cart has access to the medication cart key. LVN 16 stated it should be locked when unattended. for safety reasons.

During a review of facility's Policies and Procedures (P&P) titled, Medication storage in the Facility revised date ,d+[DATE REDACTED] indicated medications and biologicals (a therapeutic substance, such as a vaccine or drug) are stored safely, securely and properly following manufacturers recommendations or those of the suppliers.

The P&P indicated medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The P&P also indicated under procedures only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. The P&P indicated medication rooms, carts and medication supplies are locked when not attended by a person with authorized access.

31333

2. Ensure medications and biologicals were properly stored and labeled for six of six current and discharged residents (Resident 174, 219, 231, 483, and 484).

a. Remove a discharged resident (Resident 484) antibiotic (medication to treat infection) from Unit 700 med cart and accurately account for each dose until destroyed.

b. Ensure a Lantus SoloStar (a prefilled insulin pen containing the long-acting insulin, used to manage blood sugar levels) insulin pen labeled for Resident 483 was refrigerated until opened and not stored at room temperature inside of Unit 300 med cart 2.

c. Ensure discontinued controlled medication (medications with a high abuse potential), noncontrolled medications, and bed hold (when a resident is temporarily transferred out of the facility) medications were removed from Unit 300 med cart 1 for Residents 174 and Unit 400 med cart 1 for Residents 211, 231, and 219.

These deficient practices had the potential of delayed care, exposing residents to deteriorated (less effective or potentially harmful) or contaminated medications, medication errors, and increased risk for drug loss or diversion (when prescription medicines are obtained or used illegally).

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 2.a. During a concurrent observation, interview, and record review on [DATE REDACTED] at 11:12 AM with a Licensed Vocational Nurse (LVN) 7, observed inside of Unit 700 med cart was a medication bubble pack (Unit-dose Level of Harm - Minimal harm or packaging, each bubble holds one dose of medication) labeled to contain Amoxicillin / Clavulanic acid (a potential for actual harm combination antibiotic to treat infections) 875 milligrams (mg, unit of measurement by weight) per 125 mg (, d+[DATE REDACTED] mg) with five tablets remaining for Resident 484. LVN 7 stated, I do not recognize the resident's Residents Affected - Some name. LVN 7 reviewed Resident 484's nursing progress notes and assessments and indicated, Resident 484 left the faciity on [DATE REDACTED].

During an interview on [DATE REDACTED] at 11:16 AM with LVN 14 in the presence of LVN 7, LVN 14 stated Resident 484's medication Amoxicillin / Clavulanic acid ,d+[DATE REDACTED] mg should not have remained stored in Unit 700 med cart after the resident left the facility. LVN 14 stated medications remaining in the med cart and available for use after the resident is no longer in the facility could be given to the wrong resident and risk of

a medication error.

During a concurrent record review and interview on [DATE REDACTED] at 11:43 AM with Assistant Director of Nursing (ADON) 3 on Unit 700, in the presence of LVN 7 and LVN 14, ADON 3 reviewed Resident 484's physician order summary, Medication Administration Record (MAR) for [DATE REDACTED], prescription bubble packs for Amoxicillin / Clavulanic acid ,d+[DATE REDACTED] mg stored inside of Unit 700 med cart, and the facility's drug destruction logs were reviewed. Resident 484's order summary included an order for Amoxicillin / Clavulanic acid ,d+[DATE REDACTED] mg with instructions to administer one tablet by mouth two times a day for right knee infected wound for 7 (seven) days and to give medication with food, order date [DATE REDACTED], with a start date of [DATE REDACTED] and a discontinue date of [DATE REDACTED] at 10:05 AM. ADON 3 stated the prescription label on the bubble pack indicated the facility receive 14 doses of Amoxicillin / Clavulanic acid ,d+[DATE REDACTED] mg for Resident 484. ADON 3 stated the resident's MAR for [DATE REDACTED], indicated Resident 484 was administered six (doses) of Amoxicillin / Clavulanic acid ,d+[DATE REDACTED] mg and the resident's bubble pack showed five doses remaining out of 14 total doses. ADON 3 stated she would review and see if she could find the other bubble pack or documentation of

the destruction of the three missing doses of antibiotic for Resident 484.

During an interview on [DATE REDACTED] at 1:19 PM, ADON 3 stated together with the Director of Nursing (DON), they looked for the three missing doses of antibiotic left behind after Resident 484's discharge and reviewed the facility's drug destruction logs between ,d+[DATE REDACTED] through [DATE REDACTED]. ADON 3 stated there was no record of

the destruction or disposal of the three missing doses of the resident's antibiotic, Amoxicillin / Clavulanic acid ,d+[DATE REDACTED] mg.

During a review of the facility's Policy and Procedures (P&P) titled, Medication Destruction for Non-Controlled Medications, effective date ,d+[DATE REDACTED], indicated, unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed .Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law .The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the medication disposition form:

i. Date of destruction

ii. Resident's name

iii. Name and strength of medication

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 iv. Prescription number, if applicable

Level of Harm - Minimal harm or v. Amount of medication destroyed potential for actual harm vi. Signatures of witnesses Residents Affected - Some 2.b. During a concurrent observation and interview on [DATE REDACTED] at 2:54 PM with LVN 8 on Unit 300 at med cart 2, observed inside the medication cart on the top shelf was a Lantus SoloStar Insulin Pen labeled for Resident 483 with no open date and a fill date of [DATE REDACTED]. LVN 8 stated the Lantus insulin for Resident 483 had not been opened. LVN 8 stated that Resident 483 unopened Lantus insulin should have been stored in

the refrigerator until first used or when it was opened.

According to manufacturer's labeling, Lantus SoloStar Storage Instructions: Unopened (Not in Use): Refrigerate: Store unused Lantus SoloStar pens in the refrigerator at 36 degrees ([ ] Fahrenheit [F] a temperature scale) to 46 F. Opened (In Use): Room Temperature: Once you start using a Lantus SoloStar pen, store it at room temperature, below 86 F.

During a review of the facility's P&P titled, Storage of Medications, effective date ,d+[DATE REDACTED], indicated, medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified . Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F (2 C [Celsius, a scale of temperature) to 46 F (8 C) with a thermometer to allow temperature monitoring.

2.c. During a concurrent observation and interview on [DATE REDACTED] at 3:14 PM, with LVN 9 on Unit 300 at med cart 1, inside of Unit 300 med cart 1 were multiple bubble packs of medications labeled for Resident 174. LVN 9 stated Resident 174 was transferred to the hospital on [DATE REDACTED]. LVN 9 stated Resident 174's medications should have been removed from the medication cart and stored separately from current residents in the facility when Resident 174 was not in the facility. The following bedhold medications labeled for Resident 174 were observed inside of Unit 300 MedCart 1 included:

- Carbidopa/levodopa (a combination medication used to treat Parkinson's disease, a movement disorder of

the nervous system)

- Memantine (used to treat memory loss)

- Potassium Chloride (used to treat low potassium levels)

- Irbesartan (used to treat high blood pressure)

- Amlodipine (used to treat high blood pressure)

- Donepezil (used to treat memory loss)

- Terazosin (used to treat high blood pressure and benign (not cancer) prostatic hyperplasia [enlarged prostate, a gland in men located below the bladder])

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 During an interview on [DATE REDACTED] at 3:22 PM, with LVN 10, LVN 10 stated resident's on bed hold medications should not be stored in the medication cart. LVN 10 stated that only active residents' medications in the Level of Harm - Minimal harm or facility should be stored in the medication cart. LVN 10 stated residents who are not in the facility, their potential for actual harm medications should be taken out of the med cart and not stored with active residents' orders.

Residents Affected - Some During a concurrent medication area inspection and interview on [DATE REDACTED] at 3:37 PM, with LVN 11 on Unit 400 at med cart 1, inside of Unit 400 med cart 1 the following discontinued and/or discharged residents' medications were observed stored inside of Unit 400 med cart 1 for:

a. Resident 219, Vitamin D Capsule 1.25 mg (50,000 international units - units of measure), quantity of four. LVN 11 stated Resident 219 was transferred to the hospital on [DATE REDACTED]. LVN 11 stated there is a space inside of the facility's medication room or medication cabinet to store medication of residents who are on bedhold.

b. Resident 231, Lorazepam (a controlled medication to treat anxiety, a feeling of fear or uneasiness) 0.5 mg, quantity of three tablets remaining, with a fill date of [DATE REDACTED]. LVN 11 stated that he did not know when Resident 231's order for Lorazepam was discontinued.

During a review of Resident 231's Lorazepam physician orders, indicated the resident's Lorazepam .05 mg was discontinued on [DATE REDACTED] at 7:25 PM, per MD order.

c. Resident 211, Acetaminophen (APAP, noncontrolled medication for pain) 300 mg combined with Codeine (a controlled medication for pain) 30 mg (,d+[DATE REDACTED] mg), quantity of nine tablets remaining, with a fill date of [DATE REDACTED]. LVN 11 stated, discontinued or expired controlled medications should have been given to the DON and not stored in Unit 400 med cart 1.

During an interview on [DATE REDACTED] at 4:27 PM, with ADON 2, the ADON 2 stated bedhold medications should be stored in a different location than active orders to prevent accidental administration to another resident. ADON 2 stated discontinued, expired, or discharged residents'-controlled medications should be given to the DON for destruction as soon as the order was placed to discontinue the medication. ADON 2 stated discontinued controlled medications stored in the medication cart could increase the risk of drug diversion or licensed nurses could accidentally administer the medication in error to another resident. ADON 2 stated once a controlled medication is discontinued by the prescriber, the discontinued medication should be removed from the medication cart, counted with the DON and placed in a secure locked location, and not stored with active medication orders for residents.

During a review of the facility's P&P titled, Discontinued Medications, effective date ,d+[DATE REDACTED], indicated, when medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued and securely stored until destroyed .Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 48152

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 134), preferred meal choices were implemented as requested by Resident 134.

This failure resulted in a violation of Resident 134's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition.

Findings:

During a review of Resident 134's Admission Record, the Admission record indicated Resident 134 was admitted to the facility with diagnoses that included gastroesophageal reflux disease (GERD- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and anemia (a condition where the body does not have enough healthy red blood cells)

During a review of Resident 134's Minimum Data Set (MDS- a resident assessment tool), dated 3/18/2025,

the MDS indicated Resident 134 with moderately impaired cognitive skills (ability to understand and make decisions) and usually understood when expressing ideas and wants. The MDS also indicated Resident 134 was setup or clean-up assistance (helper helps only prior to or following the activity completion) with eating, oral hygiene and substantial/maximal assistance (helper does more than half the effort needed to complete

the activity) with toileting hygiene, bathing and dressing.

During a review of Resident 134's Risk for Potential Nutritional Problems . Care Plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs), revised 4/16/2025, the Care Plan indicated Resident 134 dislikes pasta.

During a review of Resident 134's Nutritional Assessment, dated 4/16/2025, the Nutritional Assessment indicated Resident 134's dietary profile included no pasta and the facility will honor [food] preferences.

During a concurrent observation, interview and record review on 5/5/2025 at 12:32 PM with Resident 134 at Resident 134's bedside, Resident 134 was observed with a lunch tray that included chicken noodle soup. Resident 134's lunch tray card was reviewed and indicated Resident 134's dislike of pasta. Resident 134 stated the facility keeps giving her soup and dinner with pasta even though she does not like it.

During an observation and interview on 5/7/2025 at 12:38 PM at Resident 134's bedside, Resident 134's lunch tray was observed with noodles, chicken and vegetables. Resident 134 stated I didn't get that nasty soup again [ chicken noodle soup], but they gave me these noodles. Resident 134 stated she will not eat the noodles on her lunch tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0806 During a concurrent interview on 5/7/2025 at 12:46 PM with Certified Nurse Assistant 10 (CNA 10) and Resident 134, CNA 10 stated Resident 134's lunch tray served Noodles not pasta, pasta refers to Italian. Level of Harm - Minimal harm or Resident 134 responded, No, pasta is anything like noodles, pizza, pasta, then added, What do you think the potential for actual harm noodles are made of?

Residents Affected - Few During an interview on 5/8/2025 at 9:50 AM with Dietary Service Supervisor (DSS), DSS stated staff did not clarify what pasta means to Resident 134 to ensure her preferences are honored with meals. DSS also stated it is important to make sure resident preferences are honored to ensure proper nutrition and prevent weight loss.

During a review of the facility's Policy & Procedure (P&P) titled, Resident Preference Interview, revised 6/1/2017, the P&P indicated resident preferences will be reflected on the tray card and updated in a timely manner. The P&P also indicated the dietary department will provide residents with meals consistent with their preferences as indicated on the tray card.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 47362

Residents Affected - Some Based on observation, interview, and record review, the facility failed to follow proper food handling practices

in accordance with its policy and procedure by failing to ensure:

1. Two (2) can opener was clean and free of gunk (unpleasantly sticky or messy substance).

2. The apple bar from the cooling rack was properly covered.

3. Food trays were free of cracked and exposed metal that has rust (a reddish-brown substance that forms

on the surface of iron and steel because of reacting with air and water).

These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization .

Findings:

1. During a concurrent observation and interview in the kitchen on 5/5/2025 at 7:41 AM with the Dietary Director (DD), observed a can opener with gunk. DD stated the can opener was not clean and has sticky food residue. DD also stated staff did not clean it.

During an observation in the kitchen on 5/6/2025 at 6:01 AM, two can openers on the preparation table were dirty had food residue/ sticky gunk.

During an interview on 5/7/2025 at 9:37 AM with dietary aid (DA1), DA1 stated the can openers are dirty. DA1 stated the can opener had tomato sauce, it has black sticky gunk. DA 1 stated opener should be washed after every use to keep it clean.

2. During a concurrent observation and interview in the kitchen's walking refrigerator near the sink on 5/5/2025 at 7:42 AM with DD, observed two (2) trays of apple bar on the cooling rack that was not fully covered. DD stated the 2 trays of apple bar on the cooling rack was not fully covered with aluminum foil and

it should be properly sealed.

3. During a concurrent observation and interview in the kitchen on 5/6/2025 at 6:51 AM with the DD, observed food tray with crack exposing the metal part with rust. DD stated the food tray was cracked with exposed metal that has rust.

During an interview on 5/7/2025 at 9:37 AM with DA 1, DA1 stated all food from the kitchen should be covered properly, the foil should be sealed and the apple bar should not be exposed, to prevent food contamination. This can possibly cause sickness like diarrhea, stomachache, nausea. DD also stated all trays should be free of crack, sharp edges and in good condition for the safety of residents and staff, can possibly cause harm to residents and staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 During a review of facility Policy & Procedure (P&P) titled, Can Opener Use and Cleaning revised 1/1/2017, indicated purpose to establish guidelines for the use and cleaning of a can opener. The P&P also indicated Level of Harm - Minimal harm or the can opener will be sanitized between uses. potential for actual harm

During a review of facility P&P titled, Discarding of Chipped / Cracked Dishes and Single Service Items, Residents Affected - Some revised 6/1/2017, indicated to established guidelines for service ware and single service items. The P&P also indicated dietary staff will maintain a sanitary environment in the dietary department by discarding compromised service ware and single service items. The P&P indicated, the dietary staff will discard chipped or cracked dish or glass ware.

During a review of facility P&P titled, Food Storage, revised 1/1/2017, indicated purpose to establish guidelines for storing, thawing and preparing food. The P&P indicated food items will be stored, thawed and prepared in accordance with good sanitary practice. The P&P also indicated food to be frozen should be store in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers and any open products should be placed in storage containers with tight fitting lids.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47362 potential for actual harm Based on observation interview and record review the facility failed to follow its own Policy and Procedures Residents Affected - Some (P&P) titled, Food Brought in by Visitors by not labeling the food items brought by visitors to the facility with

the resident's name and date they were brought to the facility.

This failure had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for residents with stored food in the resident's refrigerator.

Findings:

During a concurrent observation and interview on 5/6/2025 at 11:58 AM with the assistant director of nursing (ADON 1) at Unit B staff breakroom. ADON 1 stated one pint of [NAME] Daz ice cream, 14 pieces of ice [NAME], one [NAME] 's coffee with straw on, and four cans of Dr. Pepper were not labeled.

During an interview on 5/7/2025 at 4:54 PM with the ADON1, ADON1 stated the resident food items brought by visitors found in the refrigerator located in Unit B staff break room were not labeled. The ADON1 stated

this can cause cross contamination and possibly can cause sickness and harm to the residents.

During an interview on 5/8/2025 at 2:08 PM with registered nurse 1 (RN 1), RN 1 stated food items brought

in by visitors were kept for one week in the refrigerator and the food items should be labeled with the residents name and date when it was bought to the facility.

During a record review of the facility's Policy and Procedure (P&P) titled, Food Brought in by Visitors, dated 5/1/2023, the P&P indicated its purpose was to provide residents with the option of having food prepared by

the resident's family brought into the facility. The P&P indicated food from outside sources should be stored

in sealable container with the resident's name and date it was brought to the facility. The P&P also indicated perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will be labeled, dated and discarded after 48 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47362 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure six (6) of 6 dumpsters (a Residents Affected - Some movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Garbage and Trashcan Use and Cleaning.

This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community.

Findings:

During an observation on 5/6/2025 at 5:52 AM 6 dumpsters located at the facility's back parking lot were overflowing lid not closed.

During concurrent observation and interview on 5/7/2025 at 9:57 AM with the dietary director (DD), DD stated the 6 dumpsters at the facility's back parking were overflowing with clear plastic bag and black plastic bag containing facility trash and kitchen trash. The DD also stated dumpsters were not supposed to be overflowing, it can attract animals' rodents and can cause cross contamination. That can cause sickness like diarrhea, stomachache to residents and staff.

During an interview on 5/8/2025 at 5:30 PM with the license vocational nurse (LVN 16), LVN 16 stated that all dumpsters and trashcans were supposed to be not overflowing, it should be closed properly because it could attract rodents, flies, insects that can cause sickness like stomachaches and diarrhea.

During a record review of the facility's Policy and Procedures (P&P) titled, Garbage and Trashcan Use and Cleaning revised 11/1/2017, the P&P indicated Food waste will be in placed in covered garbage and trashcan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47362

Residents Affected - Few Based on observation, interview, and record review, the facility failed to maintain accurate medical records for one (1) of 8 sample residents (Resident 263) by not documenting oxygen therapy (the odorless gas that is present in the air and necessary to maintain life) administration accurately.

This deficient practice had the potential not to have accurate evaluation of the residents' progression or regression of the delivery of treatment and/ or care services.

Findings:

During a review of Resident 263's Admission Record, the Admission Record indicated Resident 263 was initially admitted to the facility on [DATE REDACTED] with diagnosis which included sepsis (a serious condition in which

the body responds improperly to an infection), dysphagia (swallowing difficulties) ,muscle weakness, chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems).

During a review of Resident 263's Minimum Data Set (MDS, a resident assessment tool), dated 4/4/2025,

the MDS indicated Resident 263's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired (never /rarely made decisions). The MDS indicated Resident 263 required substantial maximal assistance (helper does more than half the effort)

on oral hygiene, toilet hygiene, personal hygiene.

During a record review of Resident 263's Order Summary Report dated 5/7/2025, indicated an order dated 2/4/2025 for Oxygen at 2 liters (L, flow of oxygen is measured in liters per minute) via nasal cannula (flexible tube that goes around your head and into your nose) Humidification: Yes, as needed (PRN) every shift.

During concurrent observation and interview on 5/5/2025 at 10:34 AM with the License Vocational Nurse (LVN) 16 in Resident 263's room, observed there was no oxygen at the resident's bedside. LVN 16 stated there was no oxygen set up/ ready for Resident 263's use at bedside in case the resident needs oxygen.

During concurrent observation in Resident 263's room and interview and record review on 5/7/2025 at12:11 PM with the Registered Nurse (RN) 1, Resident 263's order summary report for May 2025 was reviewed. RN1 stated Resident 263 has an order for oxygen at 2L via nasal canula as needed. RN1 also stated there was no set up of oxygen in resident's room.

During a concurrent interview and record review on 5/7/2025 at 1:24 PM with LVN 15, of Resident 263's medication administration record (MAR) dated 5/1/2025 to 5/31/2025. LVN 15 stated started from 5/1/2025 to 5/6/2025 and the MAR indicated that the oxygen at 2L was administered. LVN 15 also stated she did not administer the oxygen but on MAR it indicated it was administered, LVN 15 must have read and documented

it wrong.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 concurrent interview and record review on 5/7/2025 at 4:22 PM with LVN 18, Resident 263's (MAR) dated 5/1/2025 to 5/31/2025 was reviewed. LVN 18 stated MAR indicated oxygen was administered to Level of Harm - Minimal harm or Resident 263 from 5/1/2025 to 5/6/2025. LVN 18 stated she did not give oxygen. potential for actual harm

During an interview and record review on 5/7/2025 at 4:48 PM with LVN 1, Resident 263's (MAR) dated Residents Affected - Few 5/1/2025 to 5/31/2025 was reviewed. LVN 1 stated, LVN 1 did not give oxygen to Resident 263 from 5/1/2025 to 5/31/2025 but the MAR indicated it was administered. LVN 1 also stated 6 licensed nurses did not document accurately.

During the interview on 5/8/2025 at 5:28PM with LVN 16, LVN 16 stated all documents should be accurate for continuity of care and for legal purposes.

During a record review of the facility's Policy and Procedure (P&P) titled Documentation- Nursing revised date 6/1/2017 indicated to provide documentation of resident status and care given by nursing staff. The P&P indicated nursing document will be concise, clear, pertinent and accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 48152 potential for actual harm Based on interview and record review, facility failed to ensure the arbitration (a process of resolving dispute Residents Affected - Few outside of a court system which involves a neutral third party [arbitrator] who makes legally binding decisions, resolving disagreement between nursing home and the reisdent or the resident's family) agreement signed by one of three samples residents (Resident 583), included information that provided for

the use of a neutral arbitrator and the selection of a venue that is convenient to both parties [facility and residents] in accordance with the facility's policy titled Arbitration Agreement, .

This failure resulted in an incomplete understanding of the facility's arbitration agreement for Resident 538.

Findings:

During a review of Resident 583's Arbitration Agreement, signed on 5/8/2025, the agreement did not indicate information regarding the use of a neutral arbitrator and the selection of a venue convenient to both parties.

During an interview on 5/8/2025 at 2:58 PM with the Resident Ambassador (RA), the RA stated she explained the arbitration agreement to Resident 583 by reading only what was included in Resident 583's Arbitration Agreement signed on 5/8/2025. RA stated she did not inform Resident 583 about the use of the neutral arbitrator or convenient venue because it was not included in the facility's Arbitration Agreement form, and RA did not know it was necessary.

During an interview on 5/8/2025 at 3:14 PM with the Admissions Director (AD), the AD stated the facility started using this agreement four months ago (January 2025), shortened it from the previous version and did not know the arbitration agreement needed to include information about the use of a neutral arbitrator and

the selection of a convenient venue to comply with federal regulations. AD stated it is important to ensure the arbitration agreement includes all necessary regulatory language to ensure it is complete, so that residents can read and understand the arbitration agreement in full.

During a review of the facility's Policy & Procedure (P&P) titled Arbitration Agreement, revised 10/24/2022,

the P&P indicated the arbitration agreement will comply with federal and state laws and the facility administrator or designee will ensure use of the latest revision of the arbitration agreement (that complies with federal and state laws).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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** 48395 potential for actual harm Based on observation, interview and record review, the facility failed to observe infection control measures Residents Affected - Some for seven of nine sampled Residents (Residents 270, 145, 183, 324, 149, 4, and 275) as indicated on the facility's policy and procedure (P&P) when the facility failed to:

1.2.3.4. Ensure facility staff donned (to put on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments)

before entering a contact (a type of transmission-based precaution [TBP; infection control measures used in healthcare settings to prevent the spread of pathogens] used for residents with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) isolation room for Residents 270, 145, 183 and 324.

5. Ensure an enhanced barrier precaution (EBP; additional infection control measures used in healthcare settings to prevent the spread of multidrug resistant organisms [MDRO; bacteria that are resistant to multiple antibiotics]) sign was posted and a PPE supply cart was available for Resident 149.

6.7. Ensure the respiratory equipment including tubing, masks, nebulizer (a machine that changes medication from a liquid to a mist for inhaling) and yankauer (an oral suctioning tool) were changed weekly order for Residents 4 and 275 as indicated on the physician's order and facility policy.

These failures had the potential to result in the spread of bacteria and viruses to other residents in the facility.

Findings:

1. During a review of Resident 270's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of end stage renal disease (ESRD, irreversible kidney failure) and sepsis (a life-threatening blood infection) due to methicillin resistant staphylococcus aureus (MRSA, a bacteria that does not respond to antibiotics).

During a review of Resident 270's Minimum Data Set (MDS, a resident assessment tool), dated 02/26/25,

the MDS indicated the Resident 270's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 13 (cognitively intact).

During a review of Resident 270's Order Summary Report, dated 4/27/2025, the Order Summary Report indicated that Resident 270 had an order for Contact Isolation for MRSA blood/urine.

During an observation on 05/06/2025 at 5:44 AM, outside of Resident 270's room, a contact precautions sign was posted outside of the resident's room (on the wall next to the doorway) indicating for those entering the room to perform hand hygiene, wear a gown and wear gloves on room entry. CNA 2 was observed entering not donning PPE upon entering Resident 270's room.

During an interview on 5/6/25 at 5:48 AM, CNA 2 stated she entered Resident 270's room without PPE just to ask the resident if he needed anything but should have worn PPE.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 2. During a review of Resident 145's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of severe sepsis (a Level of Harm - Minimal harm or life-threatening blood infection accompanied by organ dysfunction or tissue hypoperfusion [a decrease in potential for actual harm blood flow to a specific area of the body]) with septic shock (a severe, potentially life-threatening condition where a body-wide infection leads to dangerously low blood pressure and organ dysfunction) and extended Residents Affected - Some spectrum beta lactamase (ESBL; an enzyme found in strains of bacteria that cannot be killed by many of the antibiotics that doctors use to treat infections) resistance.

During a review of Resident 145's MDS, dated [DATE REDACTED], the MDS indicated the resident was severely impaired (never/rarely makes decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 145 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with transfers (how resident moves to and from bed, chair, or wheelchair), upper and lower body dressing (the ability to dress and undress above and below the waist), personal hygiene and eating.

During a review of Resident 145's Order Summary Report dated 5/8/2025, the Order Summary Report indicated an order from 2/28/2025 for Resident 145 to have enhance barrier precautions due to indwelling device: gastrostomy (GT; a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and history of MDRO: MRSA nares (nose) and ESBL in the urine.

During a review of Resident 145's Care Plan dated 3/19/2025, Resident 145's Care Plan indicated Resident 145 was at risk for infection related to indwelling device: GT and history of MDRO: MRSA nares and ESBL urine and indicated an intervention indicating to provide care using enhanced barrier precautions.

3. During a review of Resident 183's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of metabolic encephalopathy (a problem with the brain) and hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body).

During a review of Resident 183's MDS, dated [DATE REDACTED], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 183 needed substantial/maximal assistance (helper does more than half the effort) with walking 50 feet with 2 turns, going from a sitting to a standing position, personal hygiene, and putting on/taking off footwear. Resident 183 needed partial/moderate assistance (helper does less than half the effort) with walking 10 feet, chair/bed-to-chair transfers, upper body dressing and personal hygiene and needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity, helper assists only prior to or following the activity) with eating.

During a review of Resident 183's Order Summary Report dated 5/8/2025, the Order Summary Report indicated an order from 7/10/2024 for Resident 183 to have enhanced standard precautions due to history of MRSA of the wound.

During a review of Resident 183's Care Plan dated 5/5/2025, the Care Plan indicated resident 183 was at risk for infection related to history of MDRO: MRSA of wound and indicated an intervention including to provide care to Resident 183 using enhanced barrier precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 4. During a review of Resident 324's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of end stage renal disease Level of Harm - Minimal harm or (ESRD) and type 2 diabetes mellitus (DM2; a disorder characterized by difficulty in blood sugar control and potential for actual harm poor wound healing).

Residents Affected - Some During a review of Resident 324's MDS, dated [DATE REDACTED], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. Resident 324 was dependent with putting on/taking off footwear and lower body dressing, needed substantial/maximal assistance with transfers and upper body dressing. Resident 324 needed partial/moderate assistance with personal hygiene and needed supervision or touching assistance with eating.

During a review of Resident 324's Order Summary Report dated 5/8/2025, the Order Summary Report indicated an order from 4/27/2025 for Resident 324 to have contact precautions due to MRSA of the wound.

During a review of Resident 324's Care Plan dated 5/5/2025, the Care Plan indicated Resident 324 had an actual infection of MRSA of the chest wound and included an intervention indicating to provide care using contact precautions to prevent the spread of infection within the facility.

During a review of Resident 324's Care Plan dated 4/26/2025, the Care Plan indicated Resident 324 had ineffective protection related to inadequate defenses related to impaired tissue healing (MRSA of the wound) and included an intervention to place Resident 324 on contact isolation: practice hand hygiene prior to donning gown and gloves and doff (take off) PPE prior to exiting resident room and practice hand hygiene at all times when providing care to the resident.

During an observation on 5/6/2025 at 10:11 AM outside of Residents 145, 183 and 324's room, a contact precautions sign was observed outside of the room by the door. The contact precautions sign indicated to clean hands and wear a gown and gloves upon room entry. Certified Nursing Assistant 10 (CNA 10) was observed entering the room without donning PPE and came out of the room with a basin of water, walked to

the bathroom down the hall and was then observed entering another resident's room after leaving the bathroom.

During an interview on 5/6/2025 at 10:19 AM with CNA 10, CNA 10 stated she was in Residents 145, 183 and 324's room to assist Resident 324 with a bed bath. CNA 10 stated she did not wear any PPE while assisting Resident 324 with a bed bath since the only resident on contact isolation in the room is Resident 145 and not Resident 324. CNA 10 further stated the required PPE for contact isolation is to don a gown, gloves and mask and before exiting the room to doff PPE, throw it into the trash and perform hand hygiene.

During an interview on 5/6/25 at 9:40 AM, with Infection Preventionist 1 (IP 1), IP1 stated staff should don PPE prior to entering resident's room who was on contact precaution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 interview and record review on 5/7/2025 at 9:42 AM with IP 1, the facility's policy and procedure (P&P) titled, Resident Isolation - Categories of Transmission-Based Precautions revised 7/1/2023 Level of Harm - Minimal harm or was reviewed. The P&P indicated under contact precautions that gloves (clean, non-sterile) are worn when potential for actual harm entering the room and under gown that a (clean, non-sterile) gown is worn for interaction that may involve contact with the resident or potentially contaminated items in the resident's environment. IP 1 stated the P&P Residents Affected - Some needs to be re-vamped to indicate not only gloves but a gown should also be worn prior to entering a contact isolation room and the P&P should also reflect what is indicated on the contact precautions sign which is clearly indicates both gown and gloves need to be worn prior to entering the room.

During the same interview on 5/7/2025 at 9:42 AM with IP 1, IP 1 stated regardless of what staff plan to do inside a contact isolation room, they need to don full PPE prior to entering the room because MDROs can live on a surface for a long time and if staff are not donning PPE prior to entering, they could potentially touch

an area with potential pathogens that could stay on their hand and once they touch another object, they could pass that infection on.

During an interview on 5/7/2025 at 12:12 PM with IP 1, IP 1 stated donning full PPE prior to entering a contact precautions room is not only to protect the staff and the residents in that room but to also protect the other residents at the facility whom that same staff member is providing care for on that day from contracting that MDRO pathogen.

During an interview on 5/7/2024 at 3:57 PM, with Quality Assurance 1 (QA 1), QA 1 stated staff are expected to follow the contact isolation signage to don PPE upon entering a contact precaution room to protect the residents and prevent the spread of infection in the facility.

During an interview on 5/8/2025 at 10:56 AM, with Director of Nursing (DON), DON stated contact precaution signage indicates staff need to hand sanitize, wear gown, and wear gloves upon entering the room and once pass the door frame expected the staff to be wearing PPE to prevent the spread of infection to resident and other staff.

During an interview on 5/8/2025 at 1:15 PM with IP 1, IP 1 stated Residents 145, 183 and 324's room is contact isolation. IP 1 stated Residents 145 and 183 are technically on EBP for history of MRSA and Resident 324 has the active MRSA infection and is on contact precautions, however, to avoid confusion amongst staff, the whole room is on contact precautions. IP 1 further stated it does not matter who in the room has the order for contact isolation or EBP, the whole room is to be treated as a contact isolation room and the expectation is for all staff entering the room to perform hand hygiene and don full PPE (gown and gloves) prior to entering the room.

During an interview on 5/8/2025 at 1:47 PM with QA 1, QA 1 stated all staff prior to entering a contact isolation room need to don PPE prior to entering the room. QA 1 also stated if staff do not don PPE prior to entering a contact isolation room, there is a risk of spreading infection to other elderly residents at the facility who are prone to infection.

During a review of the facility's policy and procedure (P&P) titled, Resident Isolation - Categories of Transmission-Based Precautions revised 7/1/2023, the P&P indicated its purpose was to ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. The P&P also indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental Level of Harm - Minimal harm or surfaces or resident-care items in the resident's environment. potential for actual harm i. Examples of infection requiring Contact Precautions include, but are not limited to: Residents Affected - Some 1. Gastrointestinal, respiratory, skin or wound infection or colonization with [NAME]-drug resistant organisms (e.g. [for example] MRSA).

B. Table Summary of PPE

i. Transmission Based

1. Focus: Suspected of confirmed infectious agents, specific modes of transmission, or ongoing MDRO transmission

2. PPE used for these situations: any room entry

3. Required PPE: don gloves and gown before room entry.

50594

5. During a review of Resident 149's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of sepsis (a life-threatening blood infection) and ESBL resistance.

During a review of Resident 149's MDS, dated [DATE REDACTED], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. Resident 149 was dependent on putting on/taking off footwear and lower body dressing and needed substantial/maximal assistance with going from lying to sitting on the side of the bed, rolling left and right in bed, and upper body dressing. Resident 149 needed partial/moderate assistance with personal hygiene and needed supervision or touching assistance with eating.

During a review of Resident 149's Order Summary Report dated 5/7/2025, the Order Summary Report indicated an order from 4/28/2025 for Resident 149 to have enhanced barrier precautions due to colonized (the presence of microorganisms [bacteria, viruses of fungi] on or in a person's body without causing any apparent symptoms or illness) ESBL of the urine and MRSA of the blood, pressure ulcer stage 3 (sacrococcyx [triangular bone at base of the spine]) and medical indwelling device of the midline right upper extremity.

During a review of Resident 149's Care Plan dated 4/7/2025, the Care Plan indicated Resident 149 was at risk for infection related to history of ESBL urine and indicated an intervention to provide care using enhanced barrier precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 149's Care Plan dated 4/28/2025, the Care Plan indicated Resident 149 was at risk for infection due to history of colonized ESBL, MRSA pressure ulcer stage 3 (sacrococcyx) and medical Level of Harm - Minimal harm or indwelling device in the midline right upper extremity. The Care Plan also indicated an intervention to potential for actual harm observe enhanced barrier precautions by wearing gloves and gown for the following high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, Residents Affected - Some changing briefs or assisting with toileting.

During a concurrent observation and interview on 5/6/2025 at 10:30 AM with IP 1 outside of Resident 149's room, no EBP sign or PPE supply cart was observed posted outside of Resident 149's room. IP 1 validated that there was no EBP sign, or PPE supply cart posted or available outside of Resident 149's room and stated an EBP sign should have been posted outside the resident's room and a PPE cart available for the staff to use since Resident 149 was ordered by the physician to be on EBP for her history of ESBL. IP 1 stated EBP should have been initiated for the resident upon her admission to the facility and even if there was a possibility she might have changed rooms, the EBP sign, and PPE supply cart should have followed

the resident to her new room. IP 1 further stated that EBP is to protect the at-risk resident who is more susceptible to getting an infection which may be harder to treat.

During an interview on 5/8/2025 at 1:40 PM with QA 1, QA 1 stated upon a resident's admission to the facility, it is the Infection Preventionist's job to assess and determine if the resident needs EBP and once confirmed, a sign should immediately be placed outside of their door and a PPE supply cart made available outside of the room. QA 1 stated the expected of staff would also be that prior to providing any high-contact activity with the residents, they must first don PPE since EBP is in place to protect both staff and residents from the further spread of infection.

During a review of the facility's policy & procedure (P&P) titled Standard and Enhanced Precautions revised 4/1/2024, the P&P indicated, 'Enhanced Barrier Precautions' (EBP) refers toa n infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use

during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal [breathing tube] or tracheostomy tube [breathing tube], vascular catheters [a thin flexible tube inserted into a blood vessel to allow access to the bloodstream]) and wounds or presence of unhealed pressure ulcers. The P&P further indicated under Enhanced Barrier Precautions:

C. EBP should be used for any residents who meet the above criteria whenever they reside in the Facility.

D. For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities:

i. Dressing

ii. Bathing/showering

iii. Transferring

iv. Providing hygiene

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 v. Changing linens

Level of Harm - Minimal harm or vi. Changing briefs or assisting with toileting potential for actual harm vii. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Residents Affected - Some viii. Wound care: any skin opening requiring a dressing

E. EBP are intended to be in place for the duration of a resident's stay in the Facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at high-risk.

48152

6. During a review of Resident 4's Admission Record, the Admisison Record indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses that included acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), dysphagia (difficulty swallowing) and down syndrome (a condition where a person is born with an extra copy of chromosome 21; can result in physical problems and/or intellectual disabilities).

During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated Resident 4 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 4 was dependent with eating, dressing, oral hygiene and bathing. The MDS also indicated Resident 4 received oxygen therapy.

During a review of Resident 4's Order Summary Report, the Order Summary Report indicated an order to change oxygen and nebulizer tubing every night shift every Saturday, ordered 4/25/2025.

During an observation on 5/7/2025 at 3:20 PM with the Infection Preventionist Nurse (IPN) at Resident 4's bedside, the following were observed:

a. Resident 4's [respiratory] set up bag dated 4/13/2025

b. A small nebulizer dated 4/13/2025

c. An oxygen mask (connected to nebulizer) dated 4/13/2025

d. Nebulizer tubing dated 4/13/2025

e. Undated yankauer without packaging hanging out of the set up bag.

IPN stated Resident 4's set up bag, nebulizer, mask, tubing and yankauer have not and should have been changed weekly since 4/13/2025 because that was three weeks ago. IPN stated per facility protocol, all oxygen, suction and nebulizer equipment is to be properly stored in the resident's bag, changed weekly and dated with the changed date and Yankauer covered with dated packaging. IPN also stated it is important to ensure equipment is changed weekly to prevent Resident 4 from preventable infections from equipment possibly contaminated with pathogens, bacteria and/or mold.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 7. During a review of Resident 275's Admission Record, the Admission Record indicated Resi-dent 275 was admitted to the facility on [DATE REDACTED] with diagnoses that included dementia (a progressive state of decline in Level of Harm - Minimal harm or mental abilities), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of potential for actual harm involuntary movement that may involve part or the entire body, sometimes accompanied by loss of consciousness) aphasia (a disorder that makes it difficult to speak) and dysphagia. Residents Affected - Some

During a review of Resident 275's MDS, dated [DATE REDACTED], the MDS indicted Resident 275 had severely impaired cognitive skills. The MDS indicated Resident 275 was dependent with eating, bathing, dressing, oral, personal and toileting hygiene.

During a review of Resident 275's Order Summary Report, the Order Summary Report indicated an order to change oxygen and nebulizer tubing every night shift every Wednesday, ordered 10/16/2024.

During an observation on 5/7/2025 at 3:28 PM with the IPN at Resident 275's bedside, the following were observed:

a. Resident 275's set up bag dated 4/13/2025

b. Oxygen humidifier bottle (plastic bottle of water that adds moisture to the flow of oxygen) tubing dated 4/13/2025

IPN stated Resident 275's set up bag and humidifier tubing have not and should have been changed weekly since 4/13/2025 also. IPN also stated it is important to ensure equipment is changed weekly and according to policy to prevent the introduction of infections to Resident 275.

During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 6/1/2017,

the P&P indicated all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled. The P&P also indicated oxygen items will be stored in a plastic bag to protect the equipment from dust and dirt when not in use.

During a review of the facility's P&P titled, Disposable Circuits and Supply Change, dated 5/1/2024, the P&P indicated small volume nebulizer set up will be changed every Tuesday, labeled with the date of change and stored inside a resident set up bag (labeled with name, room number, and date of change). The P&P also indicated single patient suction canisters and connecting tubing must be changed every Wednesday and Sunday night.

During a review of the facility's P&P titled Suctioning - Oropharyngeal, dated 5/1/2024, the P&P indicated yankauers are changed every 24 hours and as needed, labeled with resident's name and date when opened and returned to storage after use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 46087

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure two bedrooms measured at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms. Rooms A and C measured less than 80 sq. ft. per resident.

This deficient practice had the potential of not providing the required space for residents' personal care, or

the ability to permit the use of residents' care devices, room to visitors, and the use of personal furniture.

Findings:

During the entrance conference on 5/5/2025 at 7:35 AM with the Administrator (ADM), ADM stated according to the facility's Client Accommodation Analysis form, two resident rooms (Rooms A and C) did not measure 80 sq. ft. per resident.

During a concurrent review of the facility's Client Accommodation Analysis Form on 5/5/2025 at 4 PM with ADM, ADM stated the actual square footage of resident rooms A and B was not meeting the required room size which was as follows:

Room Number: A B

Number of beds: 3 3

Floor area: 235.93 235.93

Sr. ft. per Resident: 78.6 78.6

During a review of the facility's submitted room waiver request letter indicated a request for the waiver to be granted on the condition that there was ample room to accommodate wheelchairs and other medical equipment, as well as space for mobility and movement of ambulatory residents. There is adequate space for nursing care, and the health and safety of residents occupying these rooms are not in jeopardy. These rooms are in accordance with the special needs of the residents, and do not have an adverse effect on the residents' health and safety or impedes the ability of any resident in the rooms to attain his or her highest practicable well-being.

During multiple observations made to the rooms through 5/5/2025 to 5/8/2025, the room sizes of the above rooms did not adversely affect the residents' health and or safety.

The department is recommending approval of the room waiver submitted by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47362

Residents Affected - Few Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of 5 sampled residents (Residents 90 and 533) by failing to:

1. Ensure the bedside control (used to adjust the bed height, head of bed and/or foot of the bed) wires for Residents 90 were not exposed (occurs when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within).

2. Ensure the call light (a call bell or nurse call button) wires for Residents 533 were not exposed

3. Facility failed to ensure the trash cans were not overflowing in Room A.

These deficient practices caused an unsanitary and had potential for residents to be placed at risk for serious illness and/ or injury.

Findings:

1.During a review of Resident 90's Admission Record, the Admission Record indicated Resident 90 was initially admitted to the facility on [DATE REDACTED] with diagnosis which included diabetes mellitus (condition that causes blood sugar to rise), anemia (condition in which the body does not have enough healthy red blood cells), hemiplegia(severe or complete loss of strength) and hemiparesis ( relatively mild loss of strength).

During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool), dated 2/13/2025,

the MDS indicated Resident 90's cognitive skills (processes of thinking and reasoning) for daily decision making was intact.

During observation on 5/5/2025 at 9:56 AM at Resident 90's room, Resident 90's bed control wires were exposed.

During a concurrent observation and interview on 5/8/2025 at 12:57 PM with the Certified Nursing Assistant (CNA), CNA 11 stated wires on Resident 90's bed control was exposed and it was not acceptable and it was dangerous because it can cause/ start a fire.

During an interview on 5/8/2025 at 12:58 PM with the License Vocational Nurse (LVN) 17, LVN 17 stated exposed bed wire was not acceptable, and it can cause harm to residents and staff.

2. During a review of Resident 533's Admission Record, the Admission Record indicated Resident 533 was initially admitted to the facility on [DATE REDACTED] with diagnosis which included hypertension (blood pressure is high), diabetes mellitus, and anemia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 65 055293 Department of Health & Human Services Printed: 08/27/2025 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 055293 B. Wing 05/08/2025

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

Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 0921 During a review of Resident 533's History and Physical (H&P) dated 5/3/2025 indicated Resident 533 has

the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During observation on 5/5/2025 at 11:09 AM at Resident 533's room, Resident 533's call light wires were exposed. Residents Affected - Few

During a concurrent observation and interview on 2/8/2025 at 11:09 AM with LVN 17, LVN 17 stated Resident 553's call light wires were exposed and placed the resident at risk for accident.

3. During observation in Room A on 5/15/2025 at 3:39 PM, Room A's trash can was open and filled with used Personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses).

During an interview on 5/8/2025 at 2:04 PM with the Registered Nurse (RN 1), RN1 stated all trash cans supposedly closed all the time. RN1 also stated exposed wiring was not acceptable, it can cause harm to residents and staff's safety.

During a concurrent interview and record review on 5/8/2025 at 4:52 PM with the LVN 16, the facility's Policy and Procedures (P&P) titled Maintenance Services revised date 6/1/2017 was reviewed. LVN 16 stated, P&P indicated purpose to protect the health and safety of residents, visitors, and facility staff.

During a concurrent interview and record review on 5/8/2025 at 4:54 PM with the LVN 16, the facility's P&P titled Resident Rooms and Environment revised date 11/1/2017 was reviewed. LVN 16 stated, P&P indicated Purpose to provide residents with a safe, clean, comfortable and home like environment. LVN 16 stated the facility's P&P was not followed by the facility, exposed wiring and overflowing trashcan not safe for residents and staff and it can cause harm and sickness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 65 055293