Santa Anita Convalescent Hospital

F 0814

Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) 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.During an observation on 8/12/2025 at 8:30 AM one dumpster located at the facility's back parking lot overflowing and its lid was not closed. It contained crushed eggshells in an open box and kitchen trash. The dumpster has strong odor of spoiled /rotten food and could visually see flies flying around

the dumpster. The dumpster concurrent observation and interview on 8/12/2025 at 8:41AM at the facility's back parking lot with the staffing coordinator (SC), SC stated the dumpster was overflowing, smelly, and with a lot of flies around the dumpster. SC stated it should be closed properly and not smelly. During an

interview on 8/12/2025 at 8:46 AM with the Dietary Director (DD), DD stated dumpsters are supposed to be closed all the time, not smelly. The eggshell on the box should have been put inside the plastic before dumping it into the dumpster to prevent insects and rodents. During an interview on 8/13/2025 at 11:57 AM with Dietary Aid (DA), DA stated kitchen trashcans are lined with plastic, double-tied and placed in the dumpster outside. The DA also stated that not doing so could attract flies and insects and may lead to cross contamination, which can cause sickness like diarrhea and salmonella (bacteria that commonly causes food poisoning). During a record review of the facility's Policy and Procedures (P&P) titled, garbage and trashcan use and cleaning revised 11/1/2017, indicated The dietary staff will use garbage and trash cans according to the manufacture's guidelines. Garbage and trash cans will be cleaned routinely. I Food waste will be in placed in covered garbage and trashcan. III Sanitation of Equipment: A. Garbage and trash cans are cleaned at least daily, and more often if necessary. During a record review of the facility's P&P titled, Pest Control revised 11/1/2017, in General practices section indicated, Garbage and trach are not permitted to accumulate in any part of the facility.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 3 three sampled residents (Resident 1 and 2) by failing to:1.

Ensure toilet was free from brownish to reddish color dry substants on the toilet seat.2. Ensure that the floor was free of clutters and food stains.3. Ensure that the dirty white towel with brownish colored substance was not placed on top of the covered linen barrel.4. Ensure that the old food tray from dinner was picked up.These deficient practices caused an unsanitary and unsafe environment potentially put residents in contamination and at risk for serious illness and/ or injury.During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE REDACTED] with diagnosis which included but not limit to anxiety (common mental health condition characterized by excessive and persistent worry, fear, and nervousness), history of falling, unspecified visual loss and Type II diabetes (body cannot use insulin properly, leading to high blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/1/2025, the MDS indicated Resident 1 cognitive skills (processes of thinking and reasoning) for daily decision making was intact. During a record review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted on [DATE REDACTED] with diagnosis which included but not limited to hypertension (high blood pressure), history of falling, hyperlipidemia (a condition where there are elevated levels of fats (lipids) in the blood) and Type II diabetes (body cannot use insulin properly, leading to high blood sugar). During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (potentially requiring significant assistance with daily activities). During a concurrent

observation and interview on 8/12/2025 at 8:00 AM at Resident 1 and 2's room, with the house keeping (HK1), HK1 stated the room was dirty. The toilet seat cover was not clean, there were dry urine from yesterday. HK 1 also stated the room was dirty. During a concurrent observation and interview on 8/12/2025 at 8:06 AM in Resident 1 and 2's room, the assistant administrator (AADM), AADM stated the room's floor was cluttered with empty cups, cup covers, and food wrappers. The floor was also crusted with dirt. The toilet bowl needed cleaning, dry feces (stool) were on the toilet seat. During the same concurrent

observation and interview on 8/12/2025 at 8:06 AM with the AADM, AADM stated a dirty white towel with brownish, dry substance was on top of the white covered linen barrel. The AADM stated it should be inside

the covered white barrel. The AADM also stated the leftover food from last night should have been picked up. The AADM also stated the room needs to be clean, as this can harbor bacteria and attract insects, ants, cockroaches, and rodents. During an interview on 8/12/2025 at 10:30 AM with the infection preventionist nurse (IPN1), IPN 1 stated food from night shift should have been taken out after eating. The dirty white towel with brown crusted color substance should be inside the white barrel for infection control. Other residents might get it and wipe themselves with it. IPN 1 stated the floor should be free of clutter and clean.

IPN 1 also stated dirty toilet was not acceptable. These conditions can cause sickness that can be harmful to residents. During an interview on 8/13/2025 at 11:20 AM with Resident 1, Resident 1 stated that he was worried about the bathroom toilet not being clean. Resident 1 also stated he's worried that he might get sick because of that. During a review of the facility's policy and procedures (P&P,) titled Resident Room and Environment, revised on 11/1/2017, the P&P indicated Purpose: to provide residents with a safe, clean comfortable and homelike environment. The P&P also indicated the facility staff aim to create a personalized, homelike atmosphere, paying close attention to the cleanliness and order.

Event ID:

Facility ID:

If continuation sheet