Santa Anita Convalescent Hospital

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

was reviewed. The P&P indicated acceptable serving temperatures are not limited to the following: Casseroles - More than 140 degrees Fahrenheit Pasta - More than 140 degrees Fahrenheit Vegetables More than 140 degrees Fahrenheit Milk, Juice - Less than 41 degrees Fahrenheit Quality Assurance Nurse (QAN) stated the serving temperatures means the required temperature of food when the food gets/ is served to the residents. During a concurrent interview and record review on 8/15/2025 at 3 PM, the P&P titled Food Temperatures, revised 1/31/2019, was reviewed. Administrator (ADM) stated the serving temperatures mean when the food gets to the residents. ADM also stated the pasta and carrots served to Resident 2 for lunch today did not meet the serving temperatures. During a review of the P&P titled Food Temperatures, revised 1/31/2025, the P&P indicated if temperatures do not meet the required serving temperatures listed above, reheat the product or chill the product to the proper temperature.

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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

08/15/2025

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

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

program. The P&P also indicated when gowns are used, they are used only once and discarded into appropriate receptacle located in the room in which the procedure is performed. A review of the facility's P&P titled Categories of Transmission-Based Precautions Resident isolation, revised 7/1/2023, the P&P indicated the gown is removed, and hand hygiene is performed before leaving the resident's environment. A

review of the facility's P&P titled Infection Prevention and Control Program, revised 10/24/2025, the P&P indicated it is intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of the facility's P&P titled Hand Hygiene, revised 2/20/2025, the P&P indicated hand hygiene should be done immediately upon entering a resident occupied area and immediately upon exiting a resident occupied area. A review of the facility's P&P titled COVID-19 and Quarantine, revised 7/1/2025, the P&P indicated staff will be required to wear masks when there is an outbreak in the facility and appropriate PPE when care for a resident. A review of

the Centers of Disease Control Guidelines How to use your N95 Respirator, dated 3/12/2025, the guidelines indicated when putting on an N95 Respirator, the respirator should be placed under the chin with

the nose piece bar at the top with the nose piece mold to the shape of your nose and it should fit snugly. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-face-m

1. 4. During a concurrent observation on 8/15/2025 at 12 PM in the kitchen with Dietary Supervisor (DS)

present, the tray line was observed. Dietary Supervisor Assistant (DSA) was observed dropping a bowl of food from the refrigerator, then picking it up and continuing the tray line with the same contaminated gloves.

During an interview on 8/15/2025 at 12:10 PM in the kitchen, DS stated DSA should have changed gloves and perform hand hygiene after picking up the bowl from the floor and before touching anything in the kitchen/ continuing the tray line. DS also stated not changing gloves and performing hand hygiene is not okay because it can spread infection. 5. During an observation on 8/15/2025 at 1:18 PM in the kitchen, tray line was observed when Dietary Staff (DTS) dropped a bag of bowl lids. DTS was observed picking up the bag of bowl lids, put it on the tray line near the ready-to-eat foods and touched the tray line with the same contaminated gloves. During an interview on 8/15/2025 at 1:20 PM in the kitchen during tray line, Registered Dietician (RD) stated DTS should have changed DTS' gloves and performed hand hygiene

before continuing to work on the tray line because that can spread infection to the residents. DTS also stated, the bag of bowl lids that was picked up from the floor by the DTS should not be placed on the tray line and/ or near the ready-to- eat food items to avoid contamination of food served to the residents. A

review of the facility's Policy and Procedure (P&P) titled Food Storage, revised 6/1/2017, the P&P indicated wash hands before handling food and keep work surfaces clean and orderly. A review of the facility's P&P titled General Dietary Department, revised 10/24/2022, the P&P indicated staff should wear intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. A

review of the facility's P&P titled Hand Hygiene, revised 2/20/2025, the P&P indicated washing hands with soap and water before and after food preparation and before direct contact with food.

Event ID:

Facility ID:

If continuation sheet