Health inspection·July 18, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicates that Resident 40 does not have decision making capacity, and that the resident should not have signed the ADAF/AD. During an interview on 7/18/2025, at 2:10 P.M., with the Director of Nursing (DON), the DON stated Resident 40 has a BIMS score of 4, has fluctuating capacity, and that the resident's H&P indicates that the resident does not have the decision-making capacity. The DON further stated that Resident 40 is able to sign the ADAF, even though resident 40 has fluctuating capacity, a BIMS score of 4 and resident, and resident's H&P indicating that the resident does not have the decision making capacity. During a review of the facility policy and procedures titled Advanced Directive revised on 1/16/2025, indicated, The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment . Decision making capacity1. Upon admission the interdisciplinary team assesses the resident's decision making capacity and identifies the primary decision maker if the resident is determined not to have decision making capacity.2. The interdisciplinary team conducts ongoing review of the residents decision making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision making capacity. Changes are documented in the care plan and medical record. Event ID: Facility ID: 055036 If continuation sheet Page 2 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on interview and record review, for one of one sampled resident (Resident 4), the facility failed to ensure that Resident 40 and or the resident's representative were:1. Notified timely in writing the reason for the transfer/discharge to the hospital and send a copy of the notice to the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities).2. Notified of the facility policy for bed hold (the facility agrees to keep a resident's bed available for them, even if they temporarily leave for a hospital stay or other leave of absence), including reserve bed payment in writing.This deficient practice resulted in Resident 4 and or the resident's representative not provided with options and rights regarding transfer and discharge by the facility.During a review of Resident 4's admission Record indicated the facility admitted Resident 4 on 6/13/2023, and readmitted Resident 4 on 4/1/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), paranoid schizophrenia (a mental illness that causes people to experience distorted perceptions of reality), and major depressive disorder (a serious mental health condition where a person experiences persistent feelings of sadness, hopelessness, and a loss of interest in activities they once enjoyed). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 6/18/2025, indicated Resident 4 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 4 was independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 4's Physician Order dated 3/25/2025 at 10:28 P.M., the Physician Order indicated may transfer (Resident 4) to a general acute care hospital (GACH) with seven day bed hold. During a review of Resident 4's Nursing Progress Notes dated 3/26/2025 at 7:04 A.M., the Nursing Progress Notes indicated Resident 4 was transferred out to hospital . left in stable condition. During a review of Resident 4's Bed Hold Informed Consent Notification dated 3/26/2025, the Bed Hold Informed Consent Notification indicated that Resident/Legal representative notified by .how notified: telephone. During an interview, on 7/18/2025, at 1:43 P.M., with Licensed vocational nurse (LVN) 1, LVN 1 stated a bed hold needs to be completed in the midst of transferring the resident to the hospital. LVN 1 stated bed hold is initially completed on admission by the resident/responsible party (RP - someone chosen to act on behalf of a resident to help making decisions for the resident) and on the day the resident is transferred to the hospital. LVN 1 stated that the resident/resident presentative are notified of the bed hold and that a copy of the bed hold is either faxed or emailed to the resident/representative immediately. LVN 1 stated that bed hold notification is done so that the resident/RP are aware that the resident has a bed available to come back home to. LVN 1 stated, if not done (completing bed hold form), it means it did not happen. During an interview, on 7/18/2025, at 2:09 P.M., with the Director of Nursing (DON), the DON stated a bed hold is done for seven days depending on the resident's insurance. The DON stated, the facility does not provide written notification of the bed hold however, based on now reading the policy we should be providing written notification. During a review of the facility Policy &Procedure (P&P) titled Bed-Holds and Returns revised 1/16/2025, the P&P indicated, Policy statement: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold.1. All resident/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice:a. Notice 1: well in advance of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055036 If continuation sheet Page 3 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 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 0628 transfer (e.g., in the admission packet); and b. Notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055036 If continuation sheet Page 4 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of one sampled residents (Resident 18). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 18. During a review of Resident 18's admission record, the admission record indicated the facility admitted the resident on 2/7/2024 with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities) and anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 5/16/2025, the MDS indicated Resident 18's cognition (ability to think, understand, and reason was severely impaired. The MDS indicated Resident 18 required partial/moderate assistance from staff with showering, dressing and personal hygiene. The MDS also indicated Resident 18 had an active diagnoses of schizophrenia, anxiety disorder and dementia. During a review of Resident 18's Pre-admission Screening and Resident Review Level 1 (PASRR Level 1-is a preliminary assessment completed for all individuals prior to admission to determine whether an individual might have a mental illness or intellectual disability) screening results letter dated 4/23/2025, the letter indicated that due to the resident's serious mental illness, the resident required a PASRR Level II (is a person-centered evaluation that is completed for anyone identified by the Level 1 Screening as having, or suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC)). During a review of Resident 18's Notice of Attempted Evaluation letter dated 4/27/2025, the letter indicated a level II evaluation was not able to be completed due to Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 7/17/2025, Resident 18's Level 1 evaluation and Notice of Attempted Evaluation letters were reviewed. MDSC stated the Level 1 evaluation indicated Resident 18 required a level II evaluation. The MDSC stated the facility did not contact the appropriate state agency to reschedule an evaluation for Resident 18. During an interview on 7/18/2025 at 3:08 PM, the Director of Nursing (DON) stated the PASSR screened residents for mental disabilities and if not done could result in the resident not receiving the appropriate care. During a review of the facility's policy and procedures titled, PASRR Completion Policy, reviewed 1/16/2025, indicated, The center will make a sure that all admissions have the appropriate patient assessment and resident review completed. Event ID: Facility ID: 055036 If continuation sheet Page 5 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a comprehensive resident specific care plan in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised 1/16/2025 for one of one sampled resident (Resident 1). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 1.During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/5/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), hepatic encephalopathy (a brain disorder that happens when a damaged liver can't properly filter toxins from the blood, leading to a buildup of these toxins in the brain), and diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/10/2025, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), and preferred language as Chinese. The MDS indicated Resident 1 required set up/clean up assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan initiated on 6/16/2025 indicated a focus of altered thought process related to being Chinese speaking only. and interventions included Chinese translator when available. During a concurrent interview and record review, on 7/15/2025, at 1:09 P.M., with Licensed Vocation Nurse (LVN) 2, Resident 1's care plan was reviewed. LVN 2 stated Resident 1 is Chinese speaking and staff members use gestures and pointing to communicate. LVN 2 stated LVN 2 has not used the facility translator phone or number before and that the care plan indicated translator available when needed. LVN 2 stated the facility staff need to utilize a translator when Resident 1 does not understand what the facility staff are saying or when the facility staff does not understand what Resident 1 is saying. LVN 2 stated it is Resident 1's right to be able to understand the facility staff, free speech, and that Resident 1 needs to understand what is going on around him (Resident 1). LVN 2 stated Resident 1 is a resident at the facility and deserves to know what is going on in the facility and with his health. During an interview, on 7/18/2025, at 2:42 P.M., with the Director of Nursing (DON), the DON stated for residents that are non-English speaking, the facility staff use communication boards, and translator phones. The DON stated she does not know what language Resident 1 speaks, however, the communication board alone is enough to communicate with the resident even when it comes to medication pass. The DON stated that the facility staff do not tell the residents the medications they are getting during a medication pass and are only told what the residents are taking only if they ask. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 1/16/2025, the care plan indicated, Policy statement: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.4. Each residents comprehensive person centered care plan will be consistent with the residents rights to participate in the development and implementation of his or her plan of care, including the right to:g. receive the services and/or items included in the plan of care. Event ID: Facility ID: 055036 If continuation sheet Page 6 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 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 potential for actual harm Based on interview and record review, the facility failed to follow its policy regarding laundry hot water temperature monitoring on a daily basis. This deficient practice had the potential to result in the spread infection throughout the facility.During a concurrent interview and record review, on 7/17/2025, at 3:39 P.M., with the Laundry Aid (LA) 1, the facility's temperature log for 7/2025 for the washer, dryer, and sink was reviewed. LA 1 stated that the temperature log is used to document the washer temperature and the dryer temperature. LA 1 stated, the Dryer temperature is checked every two hours, and the washer is checked every time when we do a new cycle. LA 1 stated temperature checking and logging is done to make sure that the temperature is normal or the right temperature is used to wash and dry residents' clothes. LA 1 stated the right temperature for the washer is 170 degrees Fahrenheit (unit of measure for temperature) and the dryer is between 160 Fahrenheit and 180 Fahrenheit. LA 1 stated for the month of 7/2025, the temperature log was incorrectly completed from 7/1/2025 to 7/17/2025 because the section for documenting the temperature was supposed to be recorded in numbers that represented time instead of temperature. LA 1 stated the appropriate temperature is supposed to kill bacteria or any infection and that if the temperature is not within range or not documented on the log, it will cause a problem. LA 1 stated it is important to make sure that the correct information/temperature is documented and the regulations are followed according to the policy, so everyone knows what the temperature was at a given time. During an interview with the Infection preventionist Nurse (IPN), on 7/18/2025, at, 11:34 A.M., the IPN stated that the temperature for the washer, dryer and sink is checked to make sure that when the facility staff are washing/drying clothes that the temperature is maintained within the correct range. IPN stated that the temperature log is a communication tool and if it is not completed facility staff may not know what the temperatures were during the times that were missed possible leading to infections. During an interview with the Administrator (ADM), on 7/18/2025, at 3:40 P.M., the ADM stated laundry washers and dryers need to have temperature checked three times a shift and documented on the temperature log located in the laundry room. The ADM stated the temperature log is important for infection control. The ADM stated the facility currently has the wrong temperature log in the room, we (facility staff) had an interdisciplinary meeting, we (facility staff) have fixed it and also updated our policy to say how often the log should be completed which was not in the policy we had. During a review of the facility policy and procedures (P&P) titled Departmental (Environmental Services) Laundry and Linen, revised 7/18/2025, the P&P indicated, Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.d. Washer temperature to be checked and recorded every wash cycle and dryer temperature to be checked and recorded twice daily. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055036 If continuation sheet Page 7 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure rooms 2, 4, 6, 7, 8, 9, 11, 14, 16, 17, 18, 19, and 20 had no more than three residents and rooms [ROOM NUMBERS] had no more than six residents. This failure had the potential to have an adverse effect on the health and safety of the residents in rooms 1, 2, 4, 6, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20 and impede the ability of any resident in the room to attain his or her highest practicable well-being.During an observation on 7/15/2025 at 2:03 PM in room [ROOM NUMBER], a total of six residents were in each room. During a concurrent interview Resident 32 stated he had no issues with his room and liked where he was. Resident 49 stated he had enough space for his belongings and did not have any complaints. During an interview on 7/15/2025 at 2:10 PM with the Certified Nurse's Aide (CNA) 2, CNA 2 stated CNA 2 was able to do all of CNA 2's nursing care in room [ROOM NUMBER] without any problems and that space was not a problem. During an interview on 7/15/2025 at 2:15 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the space in room [ROOM NUMBER] had enough space to do LVN 3's nursing care. During an interview on 7/15/2025 at 2:33 PM with the facility Administrator (ADM), ADM stated ADM never received any complaints from either the residents in rooms [ROOM NUMBERS] nor from the staff who cared for the residents in rooms [ROOM NUMBERS]. During a review of the facility policy and procedures (P&P) titled, Bedrooms, revised May 2017, the P&P indicated that, all residents were provided with clean, comfortable, and safe bedrooms that meet federal and state requirements and bedrooms must accommodate no more than two residents at a time. Event ID: Facility ID: 055036 If continuation sheet Page 8 of 9 Printed: 05/15/2026 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 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 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 15 of 20 resident rooms (rooms 1, 2, 4, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20) met the space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the impacted residents.On 7/15/2025 at 1:50 PM during a general tour of the facility, Rooms 2, 4, 6, 7, 8, 9, 11, 14, 16, 17, 18, 19, and 20 were observed. room [ROOM NUMBER] and room [ROOM NUMBER] were observed with six residents each. The rooms were observed with enough space for nursing staff to provide care for the residents in the rooms. The rooms were observed with privacy curtains for each resident and with direct access to the corridors and the bathroom. During the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) on 7/17/2025 at 10 AM, there were no concerns brought up by residents who attended the meeting regarding the size of the residents' rooms. During a review of the facility Client Accommodations Analysis document dated 6/27/2025, the facility Client Accommodations Analysis document indicated the following rooms with their corresponding measurements: Room # # of beds Total Square Feet1 6 455.02 3 220.04 3 220.06 3 220.07 3 220.08 3 220.09 3 234.010 6 455.011 3 220.014 3 220.016 3 222.017 3 222.018 3 222.019 3 222.020 3 222.0 The Client Accommodation Analysis indicated the above rooms measured less than the required 80 square footage per resident in multiple resident bedrooms. For a three-bed capacity room, the square footage requirements would be at least 240 square feet. For a six-bed capacity room, the square footage requirements would be at least 480 square feet. During a review of a letter from the Administrator dated 6/27/2025, the letter indicated the Administrator was requesting a waiver for rooms 1, 2, 4, 6, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20. The letter indicated that the rooms were in accordance with the special needs of the residents and would not have an adverse effect on residents' health and safety or impede the ability of any residents in the rooms to attain his or her highest practicable well-being. During an observation on 7/15/2025 at 2:03 PM in room [ROOM NUMBER], a total of six residents were in each room. During a concurrent interview Resident 32 stated he had no issues with his room and liked where he was. Resident 49 stated he had enough space for his belongings and did not have any complaints. During an interview on 7/15/2025 at 2:10 PM with the Certified Nurse's Aide (CNA) 2, CNA 2 stated CNA 2 was able to do all of CNA 2's nursing care in room [ROOM NUMBER] without any problems and that space was not a problem. During an interview on 7/15/2025 at 2:15 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the space in room [ROOM NUMBER] had enough space to do LVN 3's nursing care. During an interview on 7/15/2025 at 2:33 PM with the facility Administrator (ADM), ADM stated ADM never received any complaints from either the residents in rooms [ROOM NUMBERS] nor from the staff who cared for the residents in rooms [ROOM NUMBERS]. The room waiver was recommended to continue and was contingent with federal regulations at accommodation of needs (483.15 e) and Resident Rights (483.10). Event ID: Facility ID: 055036 If continuation sheet Page 9 of 9