Health inspection·August 13, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of Resident 2 ' s Medication Administration Record (MAR) dated 8/1/2024-8/31/2024, the MAR indicated an order on 4/15/2024 for Resident 2 to receive Gabapentin Oral Tablet 100 milligrams (mg), three times a day for neuropathy (nerve problem that causes pain). During a review of the facility ' s Policy and Procedure titled, Medication Administration, dated 12/19/2022, the P&P indicated, staff legally authorized to administer medications need to observe resident consumption of medication and report and document refusals. Event ID: Facility ID: 055104 If continuation sheet Page 2 of 4 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 055104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection control practices as outlined in the facility ' s policy for Coronavirus Prevention and Response when one of two Certified Nursing Assistants (CNA 2) went inside a Covid-19 (Coronavirus, a highly contagious respiratory disease caused by SARS-CoV-2 virus that spreads from person to person and can cause mild to severe respiratory illness) isolation (to separate people who are sick) room of Resident 5 without wearing the required Personal Protective Equipment (PPE). Residents Affected - Few This deficient practice had the potential to spread COVID-19 throughout the facility. Findings: During a review of Resident 5 ' s admission Record (AR) dated 8/6/2024, the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (persistent high blood sugar levels) and liver cirrhosis (condition in which the liver is scarred and permanently damaged) During a review of Resident 5 ' s Minimum Data Set (MDS – a standardized assessment and care planning tool) dated 8/10/2024, the MDS indicated Resident 5 had intact cognition (ability to think, and reason) and required maximal assistance (helper does more than half the effort) for toileting and bathing. During a review of the facility ' s Line Listing (a table that summarizes information about persons who may be associated with an outbreak [sudden rise in the incidence of a disease]) dated as of 8/12/2024, the line listing indicated Resident 5 ' s roommate was positive for Covid-19 on 8/7/2024. Resident 5 was placed under Covid-19 isolation due to exposure to a Covid-19 positive roommate. During a concurrent observation and interview on 8/13/2024 at 12:25 PM, CNA 2 entered Resident 5 ' s room wearing only N95 mask (type of mask designed to achieve a very close facial fit and protect against small particles in the air). There was a signage posted outside the door of Resident 5 which indicated Novel Respiratory Precautions from the local Public Health office, dated 8/2021. The signage indicated hand hygiene and the required PPE such as gown, gloves, face mask, eye protection (goggles or face shield) and mask. CNA 2 stated Resident 5 ' s room was an isolation room and CNA 2 should be wearing the required full PPE when entering an isolation room as indicated on the room signage. CNA 2 stated the purpose of wearing the required full PPE was to prevent the spread of Covid-19. During an interview on 8/13/2024 at 12:38 PM with Infection Preventionist Nurse (IPN- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment), IPN stated all staff need to wear full PPE when entering a room with Novel Respiratory Precautions. During an interview on 8/13/2024 at 3 PM with Resident 5, Resident 5 stated Resident 5 was aware that other residents in the same room were positive for Covid-19 and that was why staff needed to wear protection (PPE). During a review of the facility ' s Policy and Procedure (P&P) titled, Coronavirus Protection and Response, dated 2022, the P&P indicated healthcare personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055104 If continuation sheet Page 3 of 4 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 055104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733 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 NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. 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: 055104 If continuation sheet Page 4 of 4