Health inspection·May 15, 2025

F 0550 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 the facility's Policy and Procedure (P&P) titled Promoting/Maintaining Resident Dignity During Mealtimes, revised 12/19/2022, the P&P indicated to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life. During a review of the facility's P&P titled Accommodation of Needs, revised 12/19/2022, the P&P indicated based on individual needs and preferences, the facility will assist the resident as much as possible in maintaining and/or achieving independent functioning, dignity, and well- being to the extent possible. Event ID: Facility ID: 055162 If continuation sheet Page 2 of 27 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 05/15/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to ensure the residents receive information to formulate an advance directive for two (2) of two sampled residents (Resident 139 and 141). This deficient practice had the potential for Resident 139 and 141 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) or health care. Findings: 1. During a review of Resident 139's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of immunodeficiency (failure of the immune system to protect the body adequately from infection) and schizoaffective disorder (a mental illness that is characterized by disturbances in thought). During a review of Resident 139's Minimum Data Set (MDS - a resident assessment tool), dated 5/11/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene and upper body dressing, but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and personal hygiene. During a record review of Resident 139's medical chart and electronic health record on 5/13/2025 at 8:42 AM, there was no advance directive acknowledgement in the resident's medical chart and electronic health record . During a concurrent record review of Resident 139's chart and interview on 5/14/2025 at 9:34 AM, the Social Services Director (SSD) stated the advance directive acknowledgement was not and should have been done within 72 hours of admission. The SSD also stated it is important to provide the resident with information to formulate an advance directive; in case of an emergency, the facility will know what type of care to provide for the resident. 2. During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a record review of Resident 141's chart/electronic record on 5/13/2025 at 9:31 AM, there was no advance directive acknowledgement in the chart/electronic record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 3 of 27 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 05/15/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm During a concurrent record review of Resident 141's medical chart and electronic health record and interview on 5/14/2025 at 9:40 AM, the Social Services Director (SSD) stated the advance directive acknowledgement was not and should have been done within 72 hours of admission. The SSD also stated it is important to provide the resident with information to formulate an advance directive; in case of an emergency, the facility will know what type of care to provide for the resident. Residents Affected - Some During a concurrent record review and interview on 5/14/2025 at 10:20 AM, the DON, the facility's Policy and Procedure (P&P) titled Resident Rights Regarding Treatment and Advance Directive, revised 12/19/2022 was reviewed. The P&P indicated on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident/resident representative would like to formulate an advance directive. The DON stated the advance acknowledgment form should be done within 72 hours of admission as indicated in the policy, so the facility may know the type of care to provide for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 4 of 27 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 05/15/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 56) psychotropic medication (substance that affect the brain's activities and influence mental processes and behaviors) was appropriate to treat the resident's specific and documented condition in accordance with the facility's policy. This deficient practice placed Resident 56 at risk for unnecessary medication and delayed provision of necessary care. Finding: During a review of Resident 56's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 56's Physician Orders, dated 1/5/2024, the Physician Orders indicated Xanax (antipsychotic-class of medication that treat mental illness) Oral Tablet 0.25 micrograms (mcg - unit of measure) give 1 tablet by mouth one time a day for anxiety as manifested by constant restlessness as evidenced by repetitive physical movement. During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 56 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer (the ability to transfer to from a bed to a chair or wheelchair). During a review of Resident 56's Medication Administration Record and Treatment Administration Records (MAR & TAR) - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for the month of 5/2025, there was no documented evidence Resident 56 was monitored for constant restlessness as evidenced by repetitive physical movement for the use of Xanax. During an observation on 5/12/2025 at 8:55 AM, Resident 56 was observed sleeping in his room. During an observation on 5/13/2025 at 10 AM, Resident 56 was observed sleeping in a Geri-chair (a specialized recliner designed to provide comfort, support, and positioning for individuals, particularly those with limited mobility, who need to sit for extended periods) during activities. During an interview on 5/15/2025 at 8:58 AM, Certified Nursing Assistant 2 (CNA 2) stated Resident 56's repetitive movements is scratching. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 5 of 27 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 05/15/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/15/2025 at 9:23 AM, CNA 3 stated Resident 56's does not have any repetitive movements. During an interview on 5/15/2025 at 9:25 AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 56 does not move a lot. LVN 1 was unable to respond to the surveyor when asked to specify the resident's repetitive movements as indicated in the order for Xanax. During an interview on 5/15/2025 at 10 AM, Registered Nurse 3 (RN 3) stated Resident 56's physician order for Xanax was not specific on the repetitive movements. RN 3 also stated the LVNs, and CNAs would not know what to look for when monitoring the resident for repetitive movements. During an interview on 5/15/2025 at 10:13 AM, the Director of Nursing (DON) stated the repetitive movements need to be clarified because it is not specific on what to look for when monitoring the resident as indicated for the use of Xanax. During a review of the facility's Policy and Procedure (P&P) titled Use of Psychotropic Medications, revised 3/17/2025, the P&P indicated psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication (s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 6 of 27 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 05/15/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's oxygen needs for one (1) of 19 sampled residents (Resident 141). This deficient practice has the potential to delay in the necessary care and services for Resident 141's oxygen therapy resulting to shortness of breath or other respiratory complications. Findings: During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 141's Physician Orders, dated 5/9/2025, the Physician Orders indicated oxygen via nasal cannula 1 liter (l- unit of measure; equals to 1000 milliliters) per minute, may titrate oxygen to maintain oxygen saturation ((level of oxygen found in a person's blood) greater than or equal to 95% as needed. During a concurrent observation and interview on 5/12/2025 at 9:03 AM, Resident 141 was observed not having the nasal cannula in her nostrils. Resident 141 was also observed moving around and was hyperventilating (rapid or deep breathing). Registered Nurse 5 (RN 5) was observed fixing Resident 141's nasal cannula and stated the nasal prongs should be in the nostrils, so the resident can get the oxygen as ordered. During a concurrent interview and record review on 5/14/2025 at 11:46 AM of Resident 141's care plans, RN 2 stated Resident 141 did not and should have had a care plan for oxygen use so the staff will know how and what to care for the resident. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plan, revised 12/19/2022, the P&P indicated the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the facility's P&P titled, Oxygen Administration, revised 5/20/2024, the P&P indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 7 of 27 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 05/15/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent injuries for two (2) of five (5) residents sampled by failing to: 1. Ensure Resident 55's feet were on a footrest while resident was seated on a wheelchair during transport. This deficient practice had the potential to cause Resident 55's feet to drag which could result in serious injuries. 2. Provide padded siderails (a barrier attached to the side of a bed) for Resident 190 who had history of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness). This deficient practice had the potential for Resident 190 to sustain injuries during a seizure disorder activity. Findings: 1. During a review of Resident 55's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included displaced comminuted fracture (broken in multiple places) of shaft of left femur (long straight part of the thigh bone). During a review of Resident 55's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 55 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 55 was dependent (helper does all the effort) with toileting hygiene, shower and required substantial/maximal assistance (helper does more than half the effort) with lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 55 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene and required supervision (helper provides cues) with eating and oral hygiene. During an observation on 5/12/2025 at 10:34 AM, Resident 55 was seen seated on a wheelchair with resident's feet on the floor while being pushed down the hallway by Certified Nursing Assistant 5 (CNA 5). The wheelchair's footrest was observed at the bottom of the wheelchair which was folded back and not used during transport. During an interview on 5/14/2025 at 10:53 AM, CNA 5 stated the wheelchairs footrest should be used to prevent Resident 55's feet from touching the floor to avoid injuries during transport. During an interview on 5/14/2025 at 12:44 PM, Registered Nurse 3 (RN 3) stated CNA 5 should have used the wheelchair's footrest to prevent dragging Resident 55's feet and potentially cause injury. During a concurrent interview and record review with RN 4 on 5/15/2025 at 9:43 AM, RN 4 stated the facility's policy and procedure on accidents and supervision indicated that the residents' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 8 of 27 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 05/15/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few environment remains free of accident hazards as possible by implementing interventions to reduce risk. RN 4 stated this included ensuring the use of footrest when transporting residents in the wheelchair. During a review of the facility's Policy and Procedure (P&P) titled, Accidents and Supervision, revised on 12/19/2022, the P&P indicated that the residents' environment will remain as free of accident hazards as possible. The policy also indicated that each resident would receive adequate supervision and assistive devices to prevent accidents including implementing interventions to reduce hazard (s) and risk (s). 2. During a review of Resident 190's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis of epilepsy (a brain condition that cause recurring seizures, which are sudden, abnormal burst of electrical activity in the brain). During a review of Resident 190's MDS dated [DATE], the MDS indicated Resident 190 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 190 was dependent with toileting hygiene, shower, lower body dressing and putting on/taking off footwear and required substantial/maximal assistance with upper body dressing and personal hygiene. The MDS further indicated Resident 190 required partial/moderate assistance with eating and oral hygiene. During a review of Resident 190's Care Plan initiated on 5/10/2025, the Care Plan indicated Resident 190 had a seizure disorder and an approach plan to protect the resident from injury. During an observation on 5/13/2025 at 2:40 PM, both of Resident 190's metal bedside rails were not padded. During a concurrent observation and interview with Resident 190 on 5/14/2025 at 8:16 AM, Resident 190's stated he only started to see the black colored pad around the metal bedside rails yesterday when he came back from having hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During an interview on 5/14/2025 at 10:43 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 190 should have padded bedside rails to prevent injuries during seizure activity. During an interview on 5/14/2025 at 12:11 PM, RN 3 stated Resident 190's bedside rails should be padded to prevent any injuries during an episode of seizures. During a review of the facility's P&P titled, Seizure Precautions, revised 12/19/2022, the P&P indicated that the facility ensures a resident is protected from injury and managed in the event of a seizure according to current standards of practice. The P& P also indicated that protecting the resident from injury and complications is paramount in seizure management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 9 of 27 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 05/15/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide the necessary respiratory care services to one (1) of one sampled resident (Resident 141) by failing to ensure the Resident 1's nasal cannula (NC - a small plastic tube, which fits into the person's nostrils [nasal prongs] for providing supplemental oxygen) for oxygen was placed correctly while the resident is receiving oxygen. Residents Affected - Few This deficient practices have the potential for Resident 141 to develop complications associated with oxygen therapy. Findings: During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 141's Physician Orders, dated 5/9/2025, the Physician Orders indicated oxygen via nasal cannula 1 liters [l- unit of measure; equals to 1000 milliliters]) per minute, may titrate oxygen to maintain oxygen saturation greater than or equal to 95% as needed. During a concurrent observation and interview on 5/12/2025 at 9:03 AM, Resident 141 was observed not having the NC prongs in her nostrils. Resident 141 was also observed moving around and hyperventilating (rapid or deep breathing). Registered Nurse 5 (RN 5) was observed fixing Resident 141's NC and stated the nasal prongs should be in Resident 141'snostrils, so the resident can get the oxygen as ordered. During an interview on 5/14/2025 at 11 AM, the Director of Nursing (DON) stated the nasal cannula/ nasal prongs should be placed in the nostrils of the resident so the resident can get the oxygen as ordered. During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, revised 5/20/2024, the P&P indicated the equipment needed for oxygen administration will depend on the type of delivery system ordered such as NC - oxygen is administered through plastic cannulas in the nostril. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 10 of 27 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 05/15/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) care was provided for one (1) of two (2) sampled residents (Resident 190) when: Residents Affected - Few 1. A pitcher full of water and a 64 ounce (oz- unit of measurement) bottled watermelon cucumber juice was left at Resident 190's bedside table. 2. A 1000 cubic centimeters (cc - units of volume on liquids) per 24 hours fluid restriction sign was not posted inside Resident 190's room. 3. A precaution sign not to use left arm with the arteriovenous shunt (AV- a surgical connection between an artery and a vein used for hemodialysis) for blood pressure [BP] reading, intravenous (IV- within the vein) access and laboratory sticks were not posted inside the room. These deficient practices had the potential to place Resident 190 at risk for fluid overload (a condition where the body has too much fluid) and complications from using left arm AV shunt site for BP, IV, and laboratory sticks. Findings: During a review of Resident 190's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis of End Stage Renal Disease (ESRD - irreversible kidney failure) with dependence on renal hemodialysis. During a review of Resident 190's Care Plan initiated on 4/17/2025, the Care Plan indicated Resident 190 required hemodialysis related to renal failure and an approach plan for 1000 cc fluid restriction per day which included the breakdown as follows: 1. Dietary: 480 cc/day 2. Nursing: 520 cc/day During a review of Resident 190's Minimum Data Set (MDS- a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 190 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 190 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and personal hygiene. The MDS further indicated Resident 190 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene. During a review of Resident 190's physicians order dated 5/3/2025 at 9:30 AM, the physicians order indicated fluid restriction for 1000 cc per day with the following breakdown as follows: 1. Dietary: 480 cc/day (breakfast: 240 cc, lunch: 120 cc, and dinner: 120 cc) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 11 of 27 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 05/15/2025 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 0698 2. Nursing: 520 cc/day (7-3 shift: 200 cc, 3-11 shift: 200 cc, and 11-7 shift:120 cc) Level of Harm - Minimal harm or potential for actual harm During an observation on 5/12/2025 at 8:42 AM, Resident 190 was in bed with a left arm AV shunt and no sign posted inside the room to indicate not to take blood pressure or blood draw on the left arm and a sign to indicate fluid restriction. Resident 190 was observed with a full pitcher of water (approximately 946 cc) and 64 fluid oz of bottled watermelon cucumber juice at bedside with approximately 1/8 of the content left. Residents Affected - Few During an interview on 5/13/2025 at 9:41 AM, Resident 190 stated the facility staff provided water to him but was not limited to how much he could drink. During an interview on 5/14/2025 at 8:08 AM, Certified Nursing Assistant 6 (CNA 6) stated she does not measure Resident 190's fluid intake. CNA 6 stated she was aware Resident 190 was on fluid restriction but did not know how much. CNA 6 also stated Resident 190 was on fluid restriction due to poor kidney function. CNA 6 further stated fluids could go to Resident 190's lungs and complicate the situation which could end up with the resident hospitalized if given too much fluid. During another interview on 5/14/2025 at 8:16 AM, Resident 190 stated the facility staff does not measure how much he drinks and was not aware how much he was allowed to drink. Resident 190 also stated he only drinks whatever was provided to him. During an interview on 5/14/2025 at 10:40 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 190's fluid intake should be accurately monitored to prevent fluid overload. During an interview on 5/14/2025 at 12:20 PM, Registered Nurse 3 (RN 3) stated Resident 190 should never have a full pitcher of water at bedside and fluid intakes should be monitored accurately to prevent fluid overload. RN 3 also stated that a fluid restriction sign should be posted inside resident's room including a sign not to use the arm where the AV shunt was for BP, IV access and laboratory sticks for residents with AV shunts. During an interview on 5/15/2025 at 3:49 PM, CNA 7 stated Resident 190's AV shunt was on the right arm and takes the residents blood pressure on the left arm. CNA 7 was aware of Resident 190's fluid restriction but did not know how much. CNA 7 also stated it would be helpful to have a sign posted inside Resident 190's room which arm not to do BP, and a sign posted how much fluid the resident was restricted. During a review of the facility's Policy and Procedure (P&P) titled, Hemodialysis, revised on 6/5/2023, indicated that the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents goals and preferences, to meet the special medical, nursing, mental, and psychological needs of residents receiving hemodialysis. The P&P also indicted guidelines which included that the resident will not receive blood pressure or laboratory sticks on the arm where the dialysis access device is located. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 12 of 27 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 05/15/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper use and follow the physician's order for use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for six (6) of 6 sampled residents (Resident 1, 2, 17, 26, 56 and 69), as indicated in the facility's policy and procedure. This deficient practice had the potential to place Residents 2, 17, 26, 56 and 69 at risk for entrapment (residents becomes caught or trapped in spaces around a bed rail) which could result in injury and death. This deficient practice resulted in Resident 1 getting trapped on the bed rails on 3/25/2025, wherein Resident 1's stomach was caught on the side rail (middle section of the bed) with the resident's upper body off the bed with his head touching the floor, while his lower body was on the bed, and Resident 1 sustaining a half centimeter (cm, unit of measure) cut on the nose bridge. Findings: 1. During a review of Resident 56's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 56's Care Plan with focus on Side Rails Management, revised 1/30/2025, the Care Plan indicated to check bed, mattress and rail for appropriateness. During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 56 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer (the ability to transfer to from a bed to a chair or wheelchair) During a review of Resident 56's Physician's Order, dated 5/5/2025, the Physician's Order indicated bilateral quarter length side rails up per family request. Monitor resident every shift for appropriate position/movement while in bed that may contribute for possible entrapment. During an observation on 5/12/2025 at 8:55 AM, Resident 56 was lying in bed with the right and left side rails up in the middle section of the bed. During a concurrent interview and record review on 5/14/25 at 12:08 PM, RN 2 stated Resident 2's physician's order which indicated use of bilateral quarter length side rail was not followed. RN 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 13 of 27 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 05/15/2025 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 0700 stated a doctor's order is needed for the use of right and left side rails up in the middle section of the bed. Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 2's Admisison Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). Residents Affected - Some During a review of Resident 2's Physician's Order, dated 6/1/2022, the Physician's Order indicated Side Rails Length: ¼ Location: Bilateral, right side, left side. Monitor resident every shift for appropriate position/movement while in bed. During a review of Resident 2's Care Plan with focus on Side rails management, revised 11/18/2023, the Care Plan indicated to check bed, mattress and rail for appropriateness. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene and chair/bed to chair transfer. During an observation on 5/12/2025 at 9:44 AM, Resident 2 was lying in bed with the right and left side rails up in the middle section of the bed. 3. During a review of Resident 69 admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of dementia and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 69's Physician Orders, dated 1/22/2025, the Physician Orders indicated bilateral quarter length bed rails up to assist with mobility, turning and repositioning by providing a grasp every shift check resident for position or movement in bed that may contribute to possible entrapment. During a review of Resident 69's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 69 was dependent with eating oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off foot wear, personal hygiene and chair/bed to chair transfer. During a review of Resident 69's Care Plan with focus on Side Rails Management, revised 5/11/2025, the Care Plan indicated to check bed, mattress and rail for appropriateness. 4. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of dementia and sepsis (a life-threatening blood infection). During a review of Resident 1's Physician Orders, dated 4/25/2025, the Physician Orders indicated bilateral quarter length assist side rails to assist to turn and reposition by providing a grasp every shift monitor resident for appropriate position/movement while in bed that may contribute to possible entrapment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 14 of 27 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 05/15/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident is severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance with toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene and chair/bed to chair transfer but is dependent with shower/bathe self. During a review of Resident 1's Care Plan with focus on Side rails management, revised 5/13/2025, the Care Plan indicated check bed, mattress and rail for appropriateness. During an interview on 5/14/2025 at 8:15 AM, RN 5 stated on 3/21/2025 at 3pm when doing rounds, RN 5 found Resident 1 with his stomach caught on the side rail (middle section of the bed) with the resident's upper body off the bed with his head touching the floor, while his lower body was on the bed. RN 5 also stated Resident 1 sustained a half centimeter (cm, unit of measure) cut on the nose bridge. During an interview on 5/14/2025 at 4:10 PM, RN 2 stated Resident 1, 2, 56 and 69's physician order was not followed because the bed side rails were ½ up when the order says ¼ up. 5. During a review of Resident 17's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included repeated falls, fracture of left femur (thigh bone) and multiple fractures of the pelvis (bony structures that support the hips and lower body). During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 17 was dependent (helper does all the effort) eating, oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 17's physicians order, dated 2/10/2025 at 9:11 PM, the physicians order indicated bilateral quarter length assist siderail up to assist to turn and reposition by providing a grasp. During an observation on 5/12/2025 at 7:58 AM, Resident 17 was in bed sleeping with both right and left half side rail located in the middle section of the bed During a concurrent interview and record review on 05/14/25 at 12:32 PM, Registered Nurse 3 (RN 3) stated the physicians order for Resident 17 was to use a quarter side rail not half side rail. RN 3 stated the physicians order should be followed. RN 3 also stated Resident 3 would be more prone to injuries if the resident tries to climb out of the side rails. RN 3 also confirmed the bed rail assessment does not address the risk for entrapment and should be included. During an interview on 5/15/2025 at 9:37 AM, RN 4 stated the facility staff did not follow the physicians order for Resident 3 to use quarter side rails. 6. During a review of Resident 26's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of Dementia (a progressive state of decline in mental abilities). During a review of Resident 26's physicians order dated 4/6/2022 at 4:46 PM, the physicians order indicated an order for bilateral quarter length side rail. The physicians' order also indicated its (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 15 of 27 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 05/15/2025 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 0700 use was to assist Resident 26 to turn by providing a grasp. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 26 was dependent on shower and required substantial/maximal assistance (helper does more than half the effort) with eating, oral, toileting and personal hygiene, upper and lower body dressing and putting on/taking off footwear. Residents Affected - Some During an observation on 5/12/2025 at 3:16 PM, Resident 26 was in bed sleeping with both right and left half side rail located in the middle section of the bed were used. During a concurrent interview and record review on 5/14/25 at 3:03 PM, the Director of Nursing (DON) confirmed that half side rails were used for Resident 17 and 26 instead of quarter side rails as ordered. During a concurrent observation and interview on 5/15/25 at 9:54 AM, Certified Nursing Assistant 8 (CNA 8) did not know what the quarter side rail from the half side rail was. CNA 8 identified the quarter side rail as half side rail and the half side rail as full side rail. During a review of the facility's Policy and Procedure (P&P) titled, Proper Use of Bed Rails, revised 12/19/2022, indicated that it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. The policy also stated that if the bed rails were used, the facility was to ensure correct installation, use, and maintenance of the rails. During a review of the facility's P&P titled Provision of Physician Ordered Services, revised 5/15/2023, the P&P indicated to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 16 of 27 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 05/15/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure the Daily Staffing Report (Nurse Staffing Information) on 5/12/2025, 5/13/2025 and 5/14/2025 was complete and posted in a prominent place readily accessible to residents, visitors, and staff in accordance with the facility's policy and procedure. Residents Affected - Some These deficient practices had the potential for residents and visitors to not be informed of the actual number of nurses providing direct care to the residents. Findings: During an observation on 5/12/2025 at 8:15 AM, the Daily Staffing Report, dated 5/12/2025, was posted on the wall across from the nurses' station, however, it was placed behind another facility form which made it not visible to residents, visitors, and staff. During an observation on 5/13/2025 at 9:05 AM, the Daily Staffing Report, dated 5/13/2025, was posted on the wall across from the nurses' station, however, it was placed behind another facility form which made it not visible to residents, visitors, and staff. The Daily Staffing Report did not include the actual direct care hours for Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA) and Restorative Nursing Assistant (RNA) for the day shift (7 am - 3pm). During an observation on 5/14/2025 at 8:30 AM, the Daily Staffing Report, dated 5/14/2025, was posted on the wall across from the nurses' station, however, it was placed behind another facility form which made it not visible to residents, visitors, and staff. The Daily Staffing Report did not include the actual direct care hours for RN', LVNs, CNAs and RNAs for the day shift. During a review of the Daily Staffing Report, Facility Staffing Assignment, and Sign-In Sheet on 5/15/2025 at 11:12 AM with the Director of Staff Development (DSD). The DSD stated the Daily Staffing Report dated 5/13/2025 and 5/14/2025 did not include the actual direct care hours of RNs, LVNs, CNA, and RNA for the day shift. During an interview on 5/15/2025 at 11:30 AM, the DSD stated the Daily Staffing Report should be visible and complete so that residents, visitors, and staff are aware of the number of staff working that day in the facility. The DSD also stated that the actual direct care hours for RNs, LVNs, CNAs, and RNAs should have been included in the Daily Staffing Report posted on 5/13/2025 and 5/14/2025 for the day shift. During an interview on 5/15/2025 at 11:54 AM, RN 1 stated the Daily Staffing Report should be visible for everyone (residents, visitors, and staff) to let the residents, visitors, and staff know if the facility is adequately staffed. During an interview on 5/15/2025 at 12:26 PM, RN 3 stated the Daily Staffing Report is posted and should be visible to the residents, visitors, and staff to let them know how many staff are working that day. RN 3 stated a low number of staff in the Posted Staffing Report could mean the facility would not be able to provide quality care for the residents. During a review of the facility Policy and Procedure (P&P) titled, Nurse Posting Staffing Information, revised 3/10/2025, the P&P indicated that the nurse staffing sheet will be posted daily and will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 17 of 27 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 05/15/2025 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 0732 Level of Harm - Potential for minimal harm include the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for residents' care per shift. The policy also indicated that the information posted will be in a prominent place readily accessible to staff, residents, and visitors. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 18 of 27 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 05/15/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review, the facility failed to ensure Dietary Aide 1 (DA 1) wore hair restraint (worn by food handlers to avoid hair getting into the food) to cover mustache and beard while in the kitchen and food storage areas. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria [tiny, single-celled living things that are found everywhere, including in and on your body] from one place to another) and harmful bacterial growth that could lead to illness for 69 of 80 medically compromised residents who receive food from the kitchen. Findings: During a concurrent observation and interview on 5/14/2025 at 10:35 AM in the kitchen, with the Dietary Service Supervisor (DSS) and DA 1, DA 1 was observed with mustache and beard and was not wearing beard mask. DA 1 stated he forgot to wear a beard mask today. DSS and DA 1 stated hair could fall into the food and could cause food contamination. DSS and DA 1 stated it was important to wear a beard mask while in the kitchen and storage areas to prevent the spread of germs (a microorganism that causes disease or illness). DSS stated that residents could get sick and potentially lead to hospitalization. During a review of the facility's Policy and Procedures (P&P) titled Food Safety and Food Storage revised 11/4/2024, the P&P indicated, staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. The P&P further indicated that Dietary staff must wear hair restraints (e.g., hair net, hat, and/or beard restraint) to prevent hair from contacting food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 19 of 27 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 05/15/2025 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 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** 3. During a review of Resident 56's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). Residents Affected - Some During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 56 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer (the ability to transfer to from a bed to a chair or wheelchair). During an observation on 5/15/2025 at 9:08 AM, Certified Nursing Assistant 1 (CNA 1) was observed providing peri-care to Resident 56. CNA 1 did not change gloves and did not perform hand hygiene after providing peri-care to Resident 56. CNA 1 using the same set of gloves was observed touching Resident 56's bed sheets and the resident's body. During an interview on 5/15/2025 at 9:16 AM, CNA 1 stated she should have removed her gloves, performed hand hygiene and changed gloves prior to touching Resident 56's bed sheets and body to prevent the spread of infection. 4. During a review of Resident 69 admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of dementia and immunodeficiency (failure of the immune system to protect the body adequately from infection). During a review of Resident 69's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 69 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer. During an observation on 5/15/2025 at 8:16 AM, CNA 1 was observed providing peri-care to Resident 69. CNA 1 did not change gloves and did not perform hand hygiene after providing peri-care to Resident 69. CNA 1 using the same set of gloves was observed applying lotion to Resident 69's whole body. During an interview on 5/15/2025 at 9:16 AM, CNA 1 stated she should have removed her gloves, performed hand hygiene and changed gloves prior to touching Resident 69 and applying lotion to the resident. CNA 1 stated it is to prevent the spread of infection. 5. During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 20 of 27 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 05/15/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a concurrent observation and interview on 5/14/2025 at 9:28 PM, CNA 4 was observed providing peri-care to Resident 141. CNA 4 did not change gloves and did not perform hand hygiene after providing peri-care to Resident 141. CNA 4 using the same set of gloves was observed touching Resident 141's bed sheets, hand and body. CNA 4 stated she should have removed her gloves, performed hand hygiene and changed gloves prior to touching Resident 141's bed sheets, hand and body to prevent the spread of infection During an interview on 5/15/2025 at 11:19 AM, the Infection Preventionist Nurse (IP) stated the CNAs should have removed her gloves, perform hand hygiene, and put on new gloves. IPN also stated the CNAs should not have touched the residents bed sheets, surfaces, and body after providing peri-care to a resident because it can spread infection. During a review of the facility's Policy and Procedure (P&P) titled Hand Hygiene, revised 12/19/2022, the P&P indicated hand hygiene is indicated and will be performed under the conditions listed in, but not limited to: 1. After assistance with personal body functions such as elimination. The P&P also indicated the use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Based on observation, interview, record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of seven (7) residents sampled for infection control care areas (Resident 49, 50, 56, 69 and 141) and in accordance with the facility's policy and procedure when: 1.a Licensed Vocational Nurse (LVN) 3 failed to don (putting on) an isolation gown prior to entering Resident 49's room who was on a Transmission Based Precaution (TBP - refers to actions [precautions] implemented in addition to standard precautions that are based upon the means of transmission [airborne, contact, and droplet] to prevent or control infections). 1.b Resident 49 who was on TBP was transported and left in the dining room area for activities on 5/12/2025 by Certified Nursing Assistant 9 (CNA 9). 2.a. LVN 2 failed to change gloves and perform hand hygiene (the process of cleaning and disinfecting hands to remove dirt, and germs) after touching multiple surfaces of Resident 50 who was on enhanced barrier precautions (EBP-refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms [MDROs-bacteria that have become resistant to multiple antibiotics, making it difficult to treat infections they cause] that employs targeted gown and glove use during high contact resident care activities). 2.b. LVN 2 failed to change gloves and perform hand hygiene after giving medications via gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings, fluids, and medications to be administered directly to the stomach common for people with swallowing problems)and before administering insulin (a hormone that helps regulate blood sugar levels, typically administered via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 21 of 27 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 05/15/2025 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 0880 subcutaneous injection [given into the layer of fat just below the skin]) injection. Level of Harm - Minimal harm or potential for actual harm 3.4., and 5. Facility failed to ensure facility staff doff (take off) Personal Protective Equipment (PPE; protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after providing peri-care (cleaning the genitals and anal area) to Residents 56, 69, and 141). Residents Affected - Some These deficient practices have the potential to spread infection to staff and residents. Findings: 1.a. During a review of Resident 49's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included scoliosis (sideways curve of a spine) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 49's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 49 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 49 required partial/moderate assistance (helper does less than half the effort) with toileting, shower, lower body dressing and putting on and taking off footwear and required supervision (helper provides cues) with eating, oral and personal hygiene, and upper body dressing. During a review of Resident 49's Care Plan initiated on 5/10/2025, the Care Plan indicated the Resident has ESBL of the urine with an approach plan to use contact isolation. During a review of Resident 49's physicians order dated 5/11/2025 at 1:22 PM, the physicians order indicated contact isolation for the resident until 5/17/2025 at 11:59 PM for extended-spectrum beta-lactamase (ESBL, are enzymes produced by some bacteria's that may make them resistant to some antibiotics) of the urine. During an observation on 5/13/2025 at 10:55 AM, Licensed Vocational Nurse 3 (LVN 3) entered Resident 49's room without wearing an isolation gown. During an interview on 5/14/2025 at 12:58 PM, the Infection Prevention Nurse (IPN) confirmed Resident 49 has ESBL of the urine. The IPN stated LVN 3 should have worn an isolation gown before going inside the resident's room to protect her and other residents from contracting the infection. During an interview on 5/14/2025 at 1:06 PM, LVN 3 stated she should have used an isolation gown because the resident is a contact isolation for ESBL of the urine and to prevent the spread of infection to others. During an interview on 5/15/2025 at 9:49 AM, the Director of Nursing (DON) stated that LVN 3 should have worn an isolation gown to protect herself from getting the infection and to prevent spreading the infection to other residents. 1.b During an observation on 5/12/2025 at 10:29 AM, Resident 49 was taken by CNA 9 to the dining room area for activities from the resident's room by wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 22 of 27 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 05/15/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/14/2025 at 12:58 PM, the IPN stated Resident 49 should not have been brought to the dining room by CNA 9 to prevent potential spread of her infection to other residents, staff, and/ or visitors. During an interview on 5/15/2025 at 9:49 AM, the DON stated Resident 49 should not have been brought to the dining room with other residents since the resident could infect other people in the dining room. During a review of the facility's Policy and Procedure (P&P) titled, Transmission -Based Precautions, revised 7/18/2023, the P&P indicated that the facility was to take appropriate precautions to prevent transmission of pathogen, based on the pathogens' mode of transmission. The policy also indicated that residents on TBP should remain in their rooms except for medically necessary care. The policy further indicated that healthcare personnel caring for the residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 2.During a review of Resident 50's admission Record, the admission Record indicated the facility admitted Resident 50 on 9/25/2020 with diagnoses including, but not limited to, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, malnutrition (a condition that occurs when the body does not receive enough nutrients or calories to function properly), and presence of GT to administer the medications and water flush. During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 had severe impairment with cognitive (the mental process that takes place in the brain, including, thinking, attention, language learning, memory, and perception) skills for daily decision making. The MDS also indicated Resident 50 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provide less that half the effort) with upper body dressing. The MDS indicated Resident 50 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) with eating, oral and personal hygiene, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 50 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene and shower or bathing self. During a review of Resident 50's Care Plan focused on GT site and continuous GT feeding, and EBP due to use of GT, initiated on 1/24/2025, the Care Plan indicated interventions which included applying enhanced barrier to prevent spread of infections for specific care activities such as caring for devices and giving medical treatments. The Care Plan also indicated following facility policy and procedures on EBP, follow EBP for the duration of use of the GT initiated on 5/24/2024. During an observation on 5/14/2025 at 8:22 AM outside Resident 50's room, LVN 2 was observed preparing Resident 50's medications. LVN 2 entered Resident 50's room with the medications. LVN 2 then grabbed the privacy curtain located between Bed A and Bed B. LVN 2 was then observed grabbing the privacy curtain by Bed A without changing gloves and performing hand hygiene. LVN 2 then proceeded to touch Resident 50's GT feeding pump (a device that delivers liquid formula or medication through a GT. It controls the rate and amount of the delivery, ensuring the patient receives the correct dosage and prevents complications) to turn it off, took out the GT feeding syringe (used to feed a resident quickly, introducing a fairly large bolus per swallow or for water flushing) from its plastic cover, touched Resident 50's gown to access the GT, placed the stethoscope's (a medical instrument that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 23 of 27 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 05/15/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some allows healthcare providers to listen to sounds produced inside the body, such as heartbeat, lung and bowel sounds, for diagnostic purposes) earpiece to LVN 2's ears and stethoscope diaphragm (circular end of the chest piece) to Resident 50's abdomen to check GT patency (condition of being unobstructed) and placement. LVN 2 proceeded to administer medications via the GT and reconnected the feeding tube. LVN 2 was then observed to administer the insulin that has been prepared to Resident 50's abdomen without changing gloves and performing hand hygiene. During an interview on 5/14/2025 at 9 AM with LVN 2, LVN 2 stated she forgot to change her gloves and perform hand hygiene after touching multiple surfaces and prior to and after administering Resident 50's medications via GT and prior to administering the resident's insulin. LVN 2 stated it was important to remove used gloves and perform hand hygiene after touching multiple surfaces and donning new gloves prior to proceeding with another task. LVN 2 stated it was important to follow standard precautions and EBP to prevent the spread of MDROs to other residents and staff. LVN 2 stated that residents could become infected and get sick because of not observing standard precautions and EBP. During a review of the facility's P&P titled, Enhanced Barrier Precautions, revised 4/22/2024, the P&P indicated: The facility is to implement EBP for the prevention of transmission of multidrug resistant organisms. EBP are indicated for residents with indwelling medical devices such as feeding tubes. High contact resident care activities include device care or use. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 24 of 27 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 05/15/2025 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to ensure one of 29 resident rooms, a multiple resident room (Room A) met the minimum square footage requirement of 80 square feet (sq. ft. unit of measurement) per resident. This deficient practice had the potential to affect the care, comfort, and services to the residents. Findings: During an observation on 5/12/2025 at 1:30 PM, Room A had three beds and three residents (Residents 28, 40, and 42) occupying the beds in the room. All three residents were on the bed and appeared comfortable. Room A had enough space for a bedside table, nightstand, and a wheelchair for each resident. During the survey period from 5/12/2025 to 5/15/2025, residents and staff were interviewed and presented no complaints regarding the size of their room. During a review of the facility's room waiver request, dated 5/15/2025, the request indicated Room A measured at 223 sq. ft. The waiver request also indicated the residents' needs were accommodated and there were no adverse effects to the health and safety and welfare of the residents occupying these rooms. During a review of the facility's Client Accommodations Analysis, dated 5/15/2024, the Client Accommodations Analysis indicated Room A measured at 223 sq. ft and was currently occupied by three residents. The Department is, therefore, recommending the waiver request for Room A. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 25 of 27 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 05/15/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure the facility was safe and sanitary by failing to: Residents Affected - Some 1. The kitchen ceiling was free from water leak stains, bubbling and paint that was peeling off. 2. One of four dumpsters was completely closed and not overflowing. This deficient practice resulted in an unsanitary and unhomelike environment and had the potential for residents to be placed at risk for serious illness and hospitalization. Findings: During a concurrent observation and interview on 5/12/2025 at 8:09 AM by the dumpster area, one of four dumpsters was observed overflowing with boxes and dumpster cover was not completely closed. The Maintenance Director stated the company that picks up the garbage has not arrived yet and they were scheduled to be picked up early this morning. During a concurrent observation and interview on 5/12/2025 at 8:13 AM inside the kitchen, with the Dietary Service Supervisor (DSS), the ceiling was observed with water stains, paint patches, bubbling and paint that was peeling off. The DSS stated that the water stains appeared after the rain two weeks ago. DSS stated it still needs to be repaired. The Maintenance Director was already informed but unable to remember the date and time of notification. During a concurrent interview and record review on 5/15/2025 at 9:30 AM with the Maintenance Director, the Policy and Procedure (P&P) titled, Disposal of Garbage and Refuse and Resident Environment Quality, both revised on 12/19/2022 were reviewed. The P&P titled, Disposal of Garbage and Refuse, indicated the facility shall properly dispose of kitchen garbage and refuse. The P&P also indicated that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. The P&P titled, Resident Environmental Quality, indicated that it was the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The Maintenance Director stated that one dumpster was overflowing with cartons/boxes, and the lid was not completely closed. The Maintenance Director stated that if the dumpster remained open, insects/animals can get into the trash and make a mess. The Maintenance Director stated the animals, or small insects can get into the facility and spread germs and disease to the residents and staff. During an interview on 5/15/2025 at 9:40 AM with the M Maintenance Director, the Maintenance Director stated that there was water leaking into the air conditioning unit when it rained two weeks ago. The Maintenance Director stated the leak was repaired and he inspected the ceilings around the area of the leak, and he did not see any water stains or bubbling of the paint. The Maintenance Director stated the kitchen ceiling was about five to six feet approximately from the source of the water leak. The Maintenance Director stated that he did not inspect the kitchen ceiling. The Maintenance Director stated that he was not aware of the water leak stain (yellow in color) in the kitchen and was only notified yesterday. The Maintenance Director stated that the peeling paint was due to the water leak damage and could fall into the food being prepared in the kitchen. The Maintenance Director stated that this could result in food contamination and residents could sick from it. The Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 26 of 27 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 05/15/2025 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 0921 Director stated that the facility policy was to fix what needed to be fixed right away. Level of Harm - Minimal harm or potential for actual harm During a review of the P&P titled, Disposal of Garbage and Refuse, the P&P indicated that dumpsters shall be emptied according to the facility contract. The P&P further indicated that the schedule for garbage pick-up should be revised, as needed, based on the volume or refused. Residents Affected - Some During a review of the P&P titled, Resident Environmental Quality, the P&P also indicated preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055162 If continuation sheet Page 27 of 27