Health inspection·September 26, 2023

F 0580 drainage with blood tinged. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Care Plan, undated, indicated to report abnormalities of the lower back open skin, failure to heal, signs and symptoms of infection, maceration (the process of skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin) to the doctor and resident/resident representative. Residents Affected - Few A review of Resident 1's Medication Review Report for the month of 09/2023 indicated an order was placed on 9/5/2023 for CBC, BMP in the morning one time for fever. A review of Resident 1's Temperature Summary for 09/2023 indicated, resident's temperature on 9/3/2023 until 9/4/2023 at 7 AM were within normal. During an interview on 9/25/2023 at 10:30 AM with Family Member (FM), the FM stated, FM visited Resident 1 on 9/2/2023 and Resident 1 was shaking, and the resident told FM she felt cold, and her back was hurting different than normal. FM stated that evening Resident 1 started vomiting. FM stated the nurse (unidentified) informed FM that Resident 1 had a slight fever, and they were contacting the doctor. FM stated the next day, 9/3/2023 Resident 1's body was shaking violently, and she was vomiting more. FM stated Resident 1 vomited so much that there was irritation on the left corner of her mouth. During an interview on 9/26/2023 at 11:49 PM with the Licensed Vocation Nurse 1 (LVN 1), LVN 1 stated, on 9/5/2023 she saw drainage on Resident 1's wound. LVN 1 stated Resident 1 had a fever the day before (9/4/2023). During a concurrent interview and record review on 9/26/2023 at 2:34 PM with LVN 1, Resident 1's progress notes dated from 9/1/2023 to 9/4/2023 was reviewed, it did not indicate Resident 1's doctor was notified for her fever. LVN 1 stated LVN 2 informed her on 9/4/2023 during the morning shift change that Resident 1 had a fever. LVN 1 stated LVN 2 said Resident 1 had a fever and was given medication and her fever went down. LVN 1 stated when Resident 1 had a fever, the doctor needed to be contacted right away. LVN 1 stated the doctor needed to be notified for the elevated temperature because the resident could have an infection and could develop sepsis especially since Resident 1 had a wound. During a concurrent interview and record review on 9/26/2023 at 2:52 PM with Registered Nurse 1 (RN 1), Resident 1's progress notes dated from 9/1/2023 to 9/7/2023 was reviewed, it did not indicate that the physician was notified of Resident 1's fever and episodes of nausea. RN 1 stated she was given report by licensed nurse (unidentified) that sometimes during other shift (from 9/3/2023 to 9/4/023) Resident 1 had a fever. RN 1 stated when a resident had a fever, nurses (general) needed to contact the physician because it might be a sign of an incoming infection. RN 1 stated she did not recall how long Resident 1 had a fever for. RN 1 stated she could not find any documentation in Resident 1's medical records that the doctor was notified of the fever prior to her shift (morning shift 7 AM to 3 PM) on 9/5/2023. RN 1 also stated on 9/6/2023, Resident 1 informed her she was nauseated and had saliva on her mouth. RN 1 stated she gave Resident 1 a basin for the nausea. RN 1 stated she did not recall notifying the doctor regarding Resident 1's nausea on 9/6/2023. During an interview on 9/26/2023 at 5:40 PM with the Director of Nursing (DON), the DON stated when a resident had a fever, the doctor needed to be notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 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 055162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754 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 0580 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Notification of Changes, revised 12/19/2022, indicated a significant change in the resident's physical status such as a clinical complication ensured that the facility would promptly inform the physician. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 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 055162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754 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 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain accurately documented medical records for one of two sampled residents (Resident 1) by failing to document the resident ' s elevated temperature from 9/3/2023 until 9/04/2023 at 7 AM. This deficient practice had the potential to cause medication errors, inconsistencies in providing the necessary care and services to Resident 1. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 8/8/2023, with diagnoses including hypertension (an abnormally high blood pressure), a non-displaced compression fraction T12 (a type of broken bone that can cause your vertebrae to collapse, making them shorter), hyponatremia (an abnormally low concentration of sodium in the blood), and type 2 diabetes mellitus (disease, involving inappropriately elevated blood glucose levels). During a review of Resident 1 ' s History and Physical (H&P, the initial clinical evaluation and examination of the patient) dated 8/10/2023, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/7/2023, indicated Resident 1 was assessed and required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility (ability to move easily from lying position, turns side to side, and positions body while in bed), transfer (how resident moves between surfaces), dressing, toilet use, and personal hygiene(practices conducive to maintaining health and preventing disease, especially through cleanliness). During an interview with Licensed Vocational Nurse 1 (LVN), on 9/26/2023 at 2:34 PM, LVN 1 stated, she was informed by the night shift (11 PM to 7 AM) nurse that Resident 1 had a fever (elevated temperature). LVN 1 stated there was no documentation of the actual elevated temperature of Resident 1 from 9/3/2023 until 9/04/2023 at 7 AM in the resident ' s medical chart (both in the paper and electronic form health record). During concurrent interview and record review with Registered Nurse (RN 1) on 9/26/2023 at 2:50 PM, Resident 1 ' s medical records were reviewed, RN 1 stated there was no documentation of the resident ' s elevated temperature from 9/3/2023 until 9/04/2023 at 7 AM. During a review of the facility ' s policy and procedures (P&P) titled, Documentation in Medical Record dated 12/19/2022, the P&P indicated, Licensed staff and interdisciplinary team members should document all assessments, observations, and services provided in the resident ' s medical record in accordance with state laws and facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 4 of 4