Health inspection·January 11, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/11/2024 at 10:20 a.m., with the Director of Nursing (DON), the DON stated the staff were expected to sit next to the resident, at eye-level, when assisting with feeding. The DON stated sitting next to the resident provided the staff an optimal angle to assess the resident for choking and to provide dignity to the resident while they were being assisted. The DON stated the staff who provide feeding assistance were supposed to sit with the residents and talk with them as a sign of respect. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Dignity, undated, the P&P indicated, When assisting with care, residents are supported in exercising their rights. For example, residents are . provided with a dignified dining experience. During a review of the facility's P&P titled, Feeding Residents, undated, the P&P indicated, Staff should be sitting down and within eye level of resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 2 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 - Few 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 provide information and education regarding an Advance Directive (a written instruction, such as a living will or durable power of attorney for healthcare, recognized under State law, relating to the provision of healthcare when the individual is incapacitated) to one of six sampled residents' (Resident 7) Responsible Party (RP). This failure had the potential to result in Resident 7's preferences for care in an emergency, or in the event she became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions, would not be identified and/or carried out by the facility staff. Findings: During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/7/2023, the MDS indicated Resident 7 was able to understand and be understood by others. The MDS indicated Resident 7's cognition (process of thinking) was severely impaired. During a review of Resident 7's History and Physical (H&P), dated 7/5/2018, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Advance Directive Acknowledgement, dated 9/13/2018, the Acknowledgement indicated Resident 7 had not executed an Advance Directive and that Resident 7 was not capable of making preferred intensity of care decisions at the time. The Advance Directive Acknowledgment indicated Resident 7 had initialed and signed the form. During a review of Resident 7's H&P, dated 1/18/2023, the H&P indicated Resident 7 had the capacity to understand and make decisions. During an interview on 1/10/2024 at 3:21 p.m., with the Social Services Director (SSD), the SSD stated she was responsible for providing information regarding Advance Directives to the residents and/or their family. The SSD stated she would review the resident's H&P to determine if the resident was capable of understanding and deciding whether they would like to execute an Advance Directive. The SSD stated Resident 7 was not capable of making medical decisions at the time the previous SSD provided the Advance Directive information and Resident 7's family should have been the ones consulted. The SSD stated the Advance Directive was not reviewed with the appropriate person and there was no indication that it was reviewed with Resident 7's RP. The SSD stated a new Acknowledgement form should have been formulated because the previous was not valid. The SSD stated the purpose of informing the resident and their family about an Advance Directive was to give them the opportunity to have in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 3 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 writing their medical wishes for the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/11/2024 at 11:09 a.m., with the Administrator (ADM), the ADM stated a resident whose H&P indicated they did not have the capacity to understand and make decisions should not be provided any information regarding executing an Advance Directive and the information should be provided to the resident's RP. The ADM stated at the time the Advance Directive Acknowledgement form was completed, Resident 7 did not have the capacity, therefore, a new Acknowledgement form should have been reviewed with Resident 7's RP anytime from 2018 until present day. The ADM stated Resident 7's RP was not given the opportunity to have in writing their life sustaining decisions for Resident 7. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Lack of Capacity- When Medical Intervention(s) Require Informed Consent, undated, the P&P indicated, As soon as reasonably possible during the admission process, an inquiry should be directive to the adult resident or, if the patient is incapacitated, to the patients surrogate decision maker as to whether or not the patient has completed an advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 4 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 95) by failing to: a. Notify the physician of a change of condition (COC) when Resident 95's blood sugar level (measure of glucose [sugar] in the blood [normal range 70- 100 milligrams [mg, unit of measurement] per (/) deciliter [dl, unit of measurement] mg/dl) was elevated on 11/8/2023. b. Notify the physician when Resident 95 began to experience congestion (an abnormal or excessive accumulation of a body fluid), gurgling (a hollow bubbling sound), wheezing, and an episode of emesis (vomiting) on 11/9/2023. These failures resulted in Resident 95 experiencing elevated blood sugar levels over a 24-hour period from 11/8/2023 to 11/9/2023, and respiratory distress and emesis on 11/9/2023. 911 (a phone number used to contact emergency services) was called one and a half hours after the resident had a COC and the paramedics pronounced the resident deceased in the facility. Findings: a. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included anemia (low level of red blood cells), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), gastrointestinal (stomach) bleed, status post percutaneous endoscopic gastrostomy ([PEG] - medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate)) replacement, and diabetes mellitus (abnormal blood sugar). During a review of Resident 95's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 10/6/2023, the MDS indicated Resident 95's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 95 was completely dependent on staff for eating, oral hygiene, personal hygiene, toileting hygiene, bathing, and dressing. The MDS indicated Resident 95 had a feeding tube. During a review of Resident 95's Care Plan titled, Diabetes, revised on 7/3/2023, the care plan indicated Resident 95 was at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus. The care plan interventions indicated staff will initiate nursing measures for hyperglycemia immediately and notify physician promptly. During a review of Resident 95's Blood Sugar Summary dated 11/8/2023, the blood sugar summary indicated the following blood sugar levels on 11/8/2023: At 5:49 a.m.- 398 mg/dl. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 5 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 At 6:00 a.m. - 398 mg/dl. Level of Harm - Actual harm At 10:58 a.m. - 340 mg/dl. Residents Affected - Few At 5:12 p.m. - 283 mg/dl. At 8:51 p.m. - 300 mg/dl. During a review of Resident 95's Medication Administration Record (MAR), for the month of November 2023, the MAR indicated Resident 95 received the following units of Regular Insulin Injection Solution (a medication that helps your body turn food into energy and controls your blood sugar levels) on the following dates and times: 11/8/2023 at 6:30 a.m. - 10 units for a blood sugar level of 398 mg/dl. 11/8/2023 at 11:30 a.m. - 8 units for a blood sugar level of 340 mg/dl. 11/8/2023 at 4:30 p.m. - 6 units for a blood sugar level of 283 mg/dl. 11/8/2023 at 9:00 p.m. - 6 units for a blood sugar of 300 mg/dl. 11/9/2023 at 6:30 a.m. -10 units for a blood sugar of 398 mg/dl. During further review of the MAR, there was no indication Resident 95's physician was notified. During a concurrent interview and record review, on 1/9/2024, at 3:18 p.m., with Registered Nurse (RN) 2, Resident 95's Blood Sugar Summary, dated 10/17/2023 to 11/8/2023, was reviewed. RN 2 stated Resident 95's blood sugar levels were elevated above 300 mg/dl over a 24-hour period. RN 2 stated blood sugar levels of above 300 (mg/dl) required intervention from the nurse. RN 2 stated Resident 95's physician should have been notified and an order for insulin obtained. RN 2 stated any blood sugar level above 275 mg/dl for more than four hours was dangerous, and nurses were expected to notify the physician. RN 2 stated the nurses should have informed the physician of Resident 95's elevated blood sugar levels so that a different medication regimen could been established. RN 2 stated elevated blood sugar levels for an extended amount of time could lead to altered mental status, a hyperglycemic coma (life-threatening disorder that can happen when blood sugar is very high), and eventually death. During an interview on 1/10/2024, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 95's blood sugar levels were usually well controlled when she took care of the resident on the 7 a.m. to 3 p.m. shift. LVN 3 stated that elevated blood sugar levels could be a sign of a developing infection and that blood sugar levels consistently above 300 mg/dL should be reported to the physician. LVN 3 stated that prolonged elevated blood sugar levels could possibly lead to altered mental status, ketoacidosis (a serious diabetes complication where the body produces excess blood acids [ketones] and can be triggered by infection or other illness), and eventually, a coma. LVN 3 stated that LVN 6 did not inform her that Resident 95's blood sugar levels were elevated prior to the start of her shift on 11/8/2023 (7 a.m. to 3 p.m.). LVN 3 stated she would have called the physician about Resident 95's elevated blood sugar levels. During an interview on 1/10/2024, at 12:55 p.m. with LVN 6, LVN 6 stated she was Resident 95's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 6 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 - Actual harm Residents Affected - Few assigned nurse on 11/7/2023 and 11/8/2023. LVN 6 stated when any resident's blood sugar level was 300 mg/dl and above, the physician should be notified because elevated blood sugar levels of 300 mg/dl or more for over 10 hours could possibly lead to altered mental status, breathing issues, and a hyperglycemic coma. LVN 6 stated on 11/8/2023 Resident 95 had a blood sugar level greater than 300 mg/dl but she (LVN 6) did not notify the physician. LVN 6 stated she did not do so, because she was busy passing medications to other residents and forgot to endorse the elevated blood sugar levels to LVN 3. During a concurrent interview and record review on 1/10/2024, at 3:03 p.m., with LVN 7, Resident 95's Blood Sugar Summary, dated 10/17/2023 and 11/8/2023, were reviewed. LVN 7 stated Resident 95's blood sugar levels were elevated above 300 mg/dl for a 24-hour period. LVN 7 stated Resident 95's physician should have been notified of the resident's elevated blood sugar levels because the increase in blood sugar levels (above 300 mg/dl) could have been caused by an underlying developing infection and elevated blood sugars could cause altered mental status and coma. During an interview, on 1/11/2024, at 10:30 a.m., with Physician 1 (the facility's Medical Director), Physician 1 stated he expected the nurses to notify the attending physician of any COC for all residents. Physician 1 stated he would have expected the nurses to notify the attending physician if the blood sugar of a resident was persistently above 300 mg/dl because elevated blood sugars caused proteins to leak into the urine. Physician 1 stated he was not notified of Resident 95's blood sugar levels. During a concurrent interview and record review, on 1/11/2024, at 1:47 p.m., with the Director of Nursing (DON), Resident 95's Blood Sugar Summary, dated 10/17/2023 and 11/8/2023, were reviewed. The DON stated on 11/8/2023, Resident 95's blood sugar levels were above 300 mg/dl for over 24-hours. The DON stated elevated blood sugar levels could be caused by an underlying infection and should have been relayed to the physician because a rise in blood sugar levels was a change of condition. The DON stated delayed treatment of elevated blood sugar levels could possibly lead to altered mental status, sweating and coma. During a review of the facility's policy and procedure (P&P) titled, Managing Diabetes, undated, the P&P indicated the facility will monitor the blood sugar levels of residents who had diabetes mellitus to ensure the diabetes was managed, and stabilized in a manner that required the least number of finger sticks. The P&P indicated blood sugar testing during illness, surgery, stress or with COC will increase, according to physician's orders. b. During a review of Resident 95's Care Plan titled, Risk for Aspiration (choking), revised on 7/3/2023, the care plan indicated Resident 95 was at risk for aspiration of food and liquids secondary to advanced dementia, Parkinson's disease, and gastrostomy (PEG). The care plan interventions indicated staff will notify the physician of changes of condition. During a review of Resident 95's COC note, dated 11/3/2023 at 12:21 a.m., the COC indicated on 11/2/2023 at 11:45 p.m., Resident 95 exhibited congestion, wheezing and a gurgling sound. The COC indicated Resident 95 was transferred to the general acute care hospital (GACH). During a review of Resident 95's GACH records titled, Procedure Notes, dated 11/4/2023, the procedure notes indicated Resident 95 had an esophagogastroduodenoscopy ([EGD]- a test to examine the lining of the gastrointestinal tract) with a gastrostomy tube replacement. The procedure notes indicated there was evidence of gastric ulcers (open sores that develop on the lining of the stomach) with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 7 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 evidence of recent bleeding. Level of Harm - Actual harm During a review of Resident 95's re-admission Patient -Alert Sheet, dated 11/7/2023, the sheet indicated Resident 95 was re-admitted to the facility from the GACH on 11/7/2023 at 7 p.m. Residents Affected - Few During a review of Resident 95's COC, dated 11/9/2023 at 7:17 a.m., the COC indicated on 11/9/2023 at 5 a.m., LVN 6 noticed Resident 95 had congestion, gurgling, and wheezing. The COC indicated at 5:15 a.m., LVN 6 administered a breathing treatment to the resident, and at 6 a.m., Resident 95 was suctioned due to vomiting a whitish amount of emesis. The COC indicated at 6:15 a.m., Resident 95 did not respond to tactile (touch) and painful stimuli, appeared pale in color with an oxygen saturation (amount of oxygen in the blood, Normal Reference Range [NRR] 92 to 100 percent [%]) of 88%, and oxygen was administered. The COC indicated chest compressions (act of maintaining blood circulation throughout the body) were started at 6:30 a.m., and 911 was called. The COC indicated Paramedics arrived at the facility at 6:40 a.m., chest compressions were resumed, and Resident 95 was pronounced deceased around 7:20 a.m. During a review of Resident 95's Medication Administration Record (MAR), for the month of November 2023, the MAR indicated on 11/9/2023 at 5:56 a.m., LVN 6 administered Ipratropium -Albuterol Inhalation Solution (a breathing treatment medication) 0.5-2.5 (3) 3mg per (/) 3 millimeters ([ml]- a unit of measurement). During an interview on 1/10/2024, at 12:41 p.m., with LVN 6, LVN 6 stated she noticed Resident 95's change in respiratory status around 2 a.m. on 11/9/2023. LVN 6 stated Resident 95 had labored breathing, was coughing, gurgling, and wheezing. LVN 6 stated she suctioned Resident 95 and administered a breathing treatment. LVN 6 stated she administered supplemental oxygen after one hour but Resident 95 was not getting better, so she suctioned the resident a second time. LVN 6 stated, at 4:00 a.m., I gave another breathing treatment and continued with my medication pass for the other residents. When I came back, he (Resident 95) was already dying around 5 a.m. LVN 6 stated, I was so busy at that time I was passing medications for 50 plus residents, and we caused a delay in care. LVN 6 stated there may have been a possibility that Resident 95 could have survived if the physician and 911 were notified or called earlier during the shift. LVN 6 stated, We called 911 late already. It should have been right away when I first noticed he (Resident 95) was having labored breathing. During a concurrent interview and record review, on 1/10/2023, at 3:03 p.m., with LVN 7, Resident 95's COC, dated 11/9/2023 at 7:17 a.m. was reviewed. LVN 7 stated the COC indicated on 11/9/2023 Resident 95's COC was identified at 5 a.m. by LVN 6, and the physician was not notified until Resident 95 had already expired. LVN 7 stated she would have checked Resident 95's vital signs immediately (at 5 a.m.), administered supplemental oxygen, and notified the physician right away. LVN 7 stated Resident 95's death could have been avoided had the physician been made aware of the elevation of Resident 95's blood sugars (on 11/8/2023) and Resident 95's symptoms of respiratory distress (on 11/9/2023). During an interview, on 1/11/2024, at 10:30 a.m., with Physician 1, Physician 1 stated there should be no delay in physician notification, especially if a resident exhibited adverse changes in respiratory status such as wheezing, gurgling, congestion, or cough because it could lead to resident's harm. During a concurrent interview and record review with the DON, on 1/11/2023, at 1:47 p.m., Resident 95's COC dated 11/9/2023 at 7:17 a.m., was reviewed. The DON stated the COC indicated on 11/9/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 8 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 - Actual harm Residents Affected - Few at 5 a.m., LVN 6 identified Resident 95's change of condition but the physician had not been notified of any changes until after Resident 95 expired. The DON stated she expected LVN 6 to notify the physician, and call 911, especially if Resident 95's COC was initially noticed by LVN 6 at 2 a.m., and if Resident 95 had not been responding to treatment. The DON stated the delay in physician notification of both Resident 95's elevated blood sugar levels and Resident 95's initial episode of respiratory distress could have contributed to Resident 95's demise. The DON stated, If 911 was called sooner, it could have led to a better outcome for the resident. The DON stated it was the expectation of all licensed nurses to notify the physician of COC and to call 911 right away, especially if the care of a resident could not be managed at the facility. During a review of the facility's P&P, titled, Change of Condition, dated 1/24/2017, the P&P indicated chest congestion or shortness of breath was considered a change of condition, and all changes of condition should be handled promptly, the physician shall be called promptly, and 911 should be called in cases of emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 9 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, notice indicating when Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] covered services are ending) to the resident's Responsible Party (RP) two days before their Medicare covered services ended for one of three sampled residents (Resident 27). Residents Affected - Few This failure had the potential to result in Resident 27's RP not having ample time to exercise their right to file an appeal. Findings: During a review of Resident 27's admission Record (Face Sheet), the admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses included but not limited to dementia (a condition characterized by progressive or persistent loss of intellectual functioning), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/19/2023, the MDS indicated Resident 27 was able to understand and be understood by others. The MDS indicated Resident 27 cognition (process of thinking) was moderately impaired. During a review of Resident 27's History and Physical (H&P), dated, 7/18/2023, the H&P indicated Resident 27 was able to make decisions for activities of daily living. During a review of Resident 27's NOMNC, undated, the NOMNC indicated Resident 27's coverage for his current skilled nursing services ended on 8/24/2023. During a review of Resident 27's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), undated, the SNFABN indicated Resident 27 and their RP were notified on 8/23/2023 that Resident 27's coverage was ending. During an interview on 1/9/2024 at 11:11 a.m., with the Business Office Manager (BOM), the BOM stated Resident 27's last date of Medicare Part A coverage was 8/24/2023 and the NOMNC should have been provided to Resident 27 and their RP no later than 8/22/2023. The BOM stated Resident 27 and their RP were notified on 8/23/2023, which meant they were notified late. The BOM stated the purpose of notifying the resident and/or the RP two days prior to their last coverage date was to ensure they were given enough notice and time to send a request to appeal. During an interview on 1/9/2024 at 1:40 p.m., with the Administrator (ADM), the ADM stated the resident and/or their RP should be provided the NOMNC no later than two days prior to their last coverage date to give sufficient time to appeal and to decide whether the resident will remain in the facility. During a review of the facility document titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, undated, the document indicated, The NOMNC must be delivered at least two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 10 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0582 calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 11 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) for one of seven sampled residents (Resident 27) who was identified as having a decline in ROM to both arms. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 27 and lead to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and a decline in overall physical functioning such as the ability to move, eat and dress. Findings: During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 7/17/2023 with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones), muscle weakness, and neuropathy (nerve damage). During a review of Resident 27's Minimum Data Set (MDS, an assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 27 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 27 required extensive assistance for bed mobility and eating and total assistance for transfers (moving from one surface to another), locomotion (ability to move from one place to another) on and off the unit, dressing, personal hygiene, and toilet use. The MDS indicated Resident 27 had no functional limitations in ROM in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 required substantial/maximal assistance for eating, oral hygiene, toilet hygiene, and bathing and total assistance in dressing and personal hygiene. The MDS indicated Resident 27 had functional ROM limitations in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's care plans, the care plans did not indicate a care plan addressing the resident's decline in ROM of both arms. During a concurrent observation and interview with Resident 27 on 1/9/2024 at 9:52 a.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the entire body. Resident 27 stated she had pain all over her body and requested pain medication. Resident 27 stated she has had more pain on the left side of the body for years and stated it was hard to move the left wrist and left shoulder. Resident 27 was unable to bring both arms overhead and was unable to make a full fist with both hands. Resident 27 stated she wished staff would assist with ROM exercises to both arms because they were painful and hard to move on her own. During a concurrent observation and interview with Resident 27 on 1/9/2023 at 2:20 p.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the body. Resident 27 stated she felt much better because she was in less pain and removed the blanket from the upper half of the body using both arms. Resident 27 moved both arms to shoulder level and bent and straightened both elbows. Resident 27 was able to make 90 (percent) % of a full fist with both hands, bent the left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 12 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 wrist downwards, and had difficulty moving the left wrist upwards due to pain. Resident 27 stated she was able to feed herself and wash her face once nursing assisted with set-up. During a concurrent interview and record review on 1/10/2024 at 2:08 p.m., with the Minimum Data Set Nurse (MDSN), Resident 27's MDS (dated 7/21/2023 and 10/19/2023), physician's orders, and care plan were reviewed. The MDSN stated the MDS was a comprehensive (inclusive, including everything necessary) assessment of a resident used to create individualized care plans. The MDSN confirmed Resident 27 had a decline in ROM to both arms and both legs according to the MDS. The MDSN stated Resident 27 was unable to demonstrate she was able to perform her activities of daily living (ADLs, basic activities such as eating, dressing, and toileting) using her arms during the MDS assessment on 10/19/2023 primarily because she was uncooperative. The MDSN stated an Interdisciplinary Team (IDT) meeting should have been initiated to ensure interventions were developed and implemented to address the limitations once the decline in ROM of Resident 27's arms and legs were identified but was not done. The MDSN stated Resident 27 should have been on therapy or RNA services to address the decline in ROM of both arms identified in the MDS but was not. The MDSN confirmed RNA services were ordered for PROM of both legs but was not ordered for the arms. The MDSN confirmed there were no interventions in place to address the change in ROM or prevent a further decline in ROM of Resident 27's arms. The MSDN stated Resident 27 was at risk for contractures because she did not get out of bed, required assistance with ADLs, and needed a lot of encouragement to participate in everyday activities. During a concurrent interview and record review on 1/10/2024 at 2:47 p.m., with the Director of Rehabilitation (DOR) who was an Occupational Therapist (OT), Resident 27's OT notes, Rehabilitation screens, joint mobility screen, and physician's orders were reviewed. The DOR stated she was unaware nursing identified Resident 27 as having a decline in arm ROM in the MDS. The DOR stated the decline in Resident 27's arm ROM should have been communicated to the rehab department in an IDT meeting but was not. The DOR stated Resident 27 was at high risk for contracture development and a functional decline because Resident 27 had a diagnosis of osteoarthritis, required assistance with mobility and ADLs, and required encouragement to move on her own. During a concurrent interview and record review on 1/11/2024 at 2:38 p.m., with the Director of Nursing (DON), Resident 27's IDT notes, MDS assessments, care plan, and physician's orders were reviewed. The DON confirmed Resident 27's had a decline in both arm ROM according to the MDS assessments. The DON confirmed Resident 27 did not have a care plan, interventions, and any services in place to address the decline in Resident 27's arm ROM. The DON stated residents with ROM impairments should be on therapy or RNA services to prevent a decline in function. The DON stated an IDT meeting should have been done, a care plan should have been created, and interventions should have been implemented once Resident 27's arm ROM decline was identified on the MDS but was not. The DON stated Resident 27 was at risk for contracture development and a functional decline because there were no interventions in place improve or prevent a decline in Resident 17's arm ROM. During a review of the facility's undated policy and procedure (P&P) titled, The Resident Care Plan, the P&P indicated the objective of comprehensive care plans was to provide individualized nursing care and to promote continuity of resident care. The P&P indicated the care plan was comprehensive in nature and generally included: identification of medical, nursing, and psychosocial needs, measurable goals, staff approaches to meet the goals, the discipline, or staff responsible for the interventions, and re-assessment and change as needed to reflect the resident's current status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 13 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the resident-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of six sampled residents (Resident 74) who had a change in her ability to carry out her activities of daily living (ADLs, term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This failure had the potential to result in Resident 74's needs not be met due to the staff being unaware of the required assistance needed. Findings: During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's History and Physical (H&P), dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, comprehensive resident assessment and care screening tool), dated 12/14/2023, the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 74's cognition was intact (ability to think and reason). The MDS indicated Resident 74 required moderate assistance with bed mobility, maximal assistance with toileting, bathing, and dressing, and required setup or clean-up assistance with personal hygiene. The MDS indicated Resident 74 had a fall with a major injury. During a review of Resident 74's Care Plan, revised 4/5/2022, the Care Plan indicated Resident 74 had self-care deficits with bed mobility that required extensive one-person assist, dressing that required total one-person assist, toileting that required total one-person assist, personal hygiene that required extensive one-person assist, and bathing that required total one-personal assist. During an interview on 1/10/2024 at 12:16 p.m., with the MDS Nurse (MDSN), the MDSN stated she was responsible for developing residents' care plans based on their MDS and to revise care plans if there were any changes in the residents' condition. The MDSN stated based on Resident 74's most current MDS on 12/14/2023 the resident's care plan on self-care deficits with bed mobility, dressing, toileting, personal hygiene, and bathing should have been revised to correctly portray her current status. The MDSN stated the residents' care plans was a communication tool with the staff and without an updated care plan for Resident 74, she potentially would not receive the proper care the required. During an interview on 1/11/2024 at 10:24 a.m., with the Director of Nursing (DON), the DON stated the purpose of care plans was to direct the staff on how to care for the resident based on their needs and goals. The DON stated care plans were revised if a resident had a change in condition, the interventions were no longer appropriate, or new interventions needed to be added according to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 14 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete needs of the resident. The DON stated Resident 74 had changes in her ability to carry out her ADLs and her care plan should have been updated to reflect those changes to ensure Resident 74 received the proper care. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, undated, the P&P indicated, Care plans shall be updated more often, as the resident's condition or needs change. Event ID: Facility ID: 055170 If continuation sheet Page 15 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 3 received report (oral communication between care providers to describe that status of the resident) for one of three sampled residents (Resident 74) who was readmitted to the facility from the general acute care hospital (GACH). Residents Affected - Few This failure resulted in the nursing staff and physician being unaware of Resident 74's computed tomography (CT, imaging that helps detect internal injuries and diseases) scan results that showed a compression fracture (type of broken bone that can cause the vertebra [bone in the spine] to collapse) of the second lumbar vertebrae (L2, bone in the lower end of the spinal column). Findings: During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's History and Physical (H&P), dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, a standardized resident asssessment and care screening tool) dated 12/14/2023, the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 82's cognition was intact (ability to think and reason). The MDS indicated Resident 74 required moderate assistance with bed mobility, maximal assistance with toileting, bathing, and dressing, and required setup or clean-up assistance with personal hygiene. The MDS indicated Resident 74 had a fall with a major injury. During a review of Resident 74's Change of Condition (COC), dated 11/6/2023, the COC indicated Resident 74 returned to her room from the shower room and was being assisted to bed by the certified nursing assistant (CNA). The COC indicated Resident 74 stood up to transfer to the bed, was unable to reach for the bed handles, and fell and landed on her back. The COC indicated Physician 2 was informed and orders for X-ray (imaging that creases pictures of the inside of the body) of the hip, spine, head, leg, and pelvis were received. The COC indicated Resident 74 complained of lower back and left hip pain. During a review of Resident 74's Radiology Results Report, dated 11/6/2023, the Radiology Results Report indicated the X-ray result of the lumbar spine indicated a compression deformity at the L2 level, age indeterminate (not exactly known). During a review of Resident 74's Progress Notes, dated 11/6/2023 and timed at 1:48 p.m., the Progress Note indicated Physician 2 was informed of Resident 74's X-ray results and Physician 2 ordered a CT scan of the head and lumbar. During a review of Resident 74's COC, dated 11/28/2023, the COC indicated Resident 74 complained of lower back pain and another lumbar X-ray was done with result of a compression deformity at the L2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 16 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few level, age determinate. The COC indicated Physician 2 was notified that Resident 74 had not received the CT scan of the head and lumbar due to insurance. The COC indicated Physician 2 ordered for Resident 74's transfer to the GACH for CT scan of the head and lumbar. During a review of Resident 74's GACH Radiology Report, dated 11/28/2023, the Radiology Report indicated the report was faxed to the facility on [DATE]. The Radiology Report indicated the CT scan result of the lumbar indicated an acute compression fracture of L2. During a review of Resident 74's (Re)admission Assessment, dated 11/28/2023, the admission Assessment indicated Resident 74 was transferred to the GACH for a CT scan of the head and lumbar and was readmitted to the facility. The admission Assessment had no indication of report from the GACH being provided to the admitting nurse from the facility and of the results of the CT scan. During a review of Resident 74's COC, dated 12/12/2023, the COC indicated the lumbar CT scan results were received from the GACH and Physician 2 was notified of the results. The COC indicated Physician 2 ordered for Resident 74 to see a neurosurgeon in one to six weeks for evaluation. During an interview on 1/10/2024 at 8:59 a.m., with Registered Nurse (RN) 2, RN 2 stated she and the other nurses were unaware of Resident 74's compression fracture until the facility received the results from the GACH. RN 2 stated Resident 74 was transferred to the GACH on her shift and was readmitted to the facility the following shift. RN 2 stated she had not received any report regarding Resident 74 while the resident was at the GACH. During an interview on 1/10/2024 at 3:46 p.m., with RN 3, RN 3 stated Resident 74 was transferred to the GACH on 11/28/2023 for a CT scan and was readmitted to the facility that same night. RN 3 stated the case manager from the GACH called her to inform her that Resident 74 would be returning to the facility, and someone would give her report. RN 3 stated normally when a resident was readmitted to the facility from the GACH, she would receive report prior to the resident's arrival. RN 3 stated she had not received report and Resident 74 was brought back to the facility. RN 3 stated she was curious what the CT scan results were, but she did not follow up with the GACH. RN 3 stated she could have called the GACH and spoken to the physician. RN 3 stated receiving report when a resident was admitted to the facility from the GACH was important in order to receive all the information that transpired at the GACH to care for the resident and collaborate with the physician. During an interview on 1/11/2024 at 10:28 a.m., with the Director of Nursing (DON), the DON stated the admitting nurse should receive report from the nurse at the GACH, especially if there were any abnormal results. The DON stated receiving report when a resident was admitted was important to know how to take care of the resident, if any precautions needed to be taken, to coordinate with other departments, in order to form a plan to care for the resident properly. During a review of the facility's policy and procedure (P&P) titled, Out-of-Facility Therapeutic Visit, undated, the P&P indicated, The facility will follow up on the recommendation from the out-of-facility therapeutic visit, if any. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 17 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0675 Honor each resident's preferences, choices, values and beliefs. 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 ensure staff provided the necessary care and services to two sampled residents (Resident 85 and 35) when: Residents Affected - Few 1. Certified Nursing Assistant (CNA) 2 failed to report Resident 85's change in condition to a licensed nurse. 2. CNA 2 failed to properly reposition Resident 85 in bed. 3. Staff did not reposition Resident 35 and Resident 85 every 2 hours. These deficient practices had the potential for Resident 85's health changes to become compromised and go unnoticed, and had the potential to result in skin breakdown or compromised skin integrity for Resident 35 and Resident 83. Findings: 1. During a review of Resident 85's admission Record, the admission record indicated Resident 85 was originally admitted to the facility on [DATE] with diagnoses including dysarthria (weakness in muscles used for speech, which often causes slowed or slurred speech) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 85's H&P dated 6/13/2023, the H&P indicated Resident 85 did not have the capacity to understand and make decisions. The H&P indicated Resident 85 had a diagnosis of chronic obstructive pulmonary disease ([COPD] group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs). During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 85 was dependent on staff for all ADLs. The MDS indicated Resident 85 had a diagnosis of hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body). During a review of Resident 85's Care Plan for Skin, dated 5/16/2023, the care plan indicated Resident 85 was at risk for developing pressure ulcers and other skin breakdown related due to fragile skin, hemiplegia, and immobility. The Care Plan indicated Resident 85's goal was to minimize the risk of skin breakdown and pressure ulcer daily. The staff's interventions indicated to turn and position Resident 85 as needed when in bed or wheelchair. During a review of Resident 85's Care Plan for Respiratory System, dated 5/16/2023, the care plan indicated Resident 85 was at risk for respiratory distress related to COPD. The care plan indicated Resident 85's goal was to not have unrecognized signs and symptoms of respiratory distress. The staff's interventions indicated to assess Resident 85 for shortness of breath, wheezing, coughing, weakness and to notify the physician promptly. During an observation on 1/8/2024 at 10:19 a.m., in Resident 85's room, Resident 85 was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 18 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0675 lying on his left side facing the wall. Level of Harm - Minimal harm or potential for actual harm During an observation 1/8/2024 at 12:44 p.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall. Residents Affected - Few During an observation on 1/9/2024 at 1:00 p.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall with no pillows between his legs. During an observation on 1/9/2024 at 3:28 p.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall. During an observation on 1/10/2024 at 7:44 a.m., in Resident 85's room, CNA 2 was observed at the resident's bedside during breakfast. Resident 85 was making grunting noises when breathing. During an observation on 1/10/2024 at 8:00 a.m., in Resident 85's room, Resident 85 was observed lying on his back, his bilateral (both) lower extremities (BLE) were contracted (a fixed tightening or shorten of muscle, tendons, ligaments, or skin) and tucked underneath him with no pillow between the legs. Resident 85 was making loud grunting noises when breathing. During an interview on 1/10/2024 at 8:14 a.m. with the Infection Preventionist Nurse (IPN), in Resident 85's room, the IPN stated Resident 85 should not have his legs in that position because it was uncomfortable and would create more of a contracture to the legs or it would cause a fracture (break in the bone) to the legs. During an observation on 1/10/2024 at 8:20 a.m., in Resident 85's room, the IPN and CNA 2 attempted to reposition Resident 85. Resident 85 could not straighten out his legs. CNA 2 kept pulling on Resident 85's legs and placed a pillow under the resident's legs. During an interview on 1/10/2024 at 8:29 a.m. with CNA 2, in Resident 85's room, CNA 2 stated she positioned Resident 85 on his back with the resident's BLE tucked under him. CNA 2 stated that positioning provided comfort to Resident 85. CNA 2 stated it was acceptable to place Resident 85 in that position without any support for his BLE because it did not cause any pain or discomfort. CNA 2 stated Resident 85 made beathing noises when she was with him. During a concurrent observation and interview on 1/10/2024 at 8:40 a.m. with the IPN, in Resident 85's room, Resident 85 was grunting loudly and struggling to breath. The IPN stated she needed to check Resident 85's oxygen saturation (percentage of oxygen circulating in the blood). The IPN stated Resident 85's oxygen saturation was 91 percent (%) (Normal Reference Range, 95% to 100%) and that she would administer oxygen to Resident 85. The IPN stated CNA 2 should have realized that Resident 85 was having trouble breathing and she should have notified a nurse. The IPN stated CNAs received in-service training to look out for any changes in residents and to notify a licensed nurse. During an interview on 1/10/2024 at 10:15 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 85's room, LVN 2 stated Resident 85 should be repositioned every 2 hours because the resident was bed bound. LVN 2 stated Resident 85 must be repositioned every 2 hours because the resident developed redness on his buttocks. LVN 2 stated Resident 85 would benefit from frequent position changes to relieve skin pressure and promote circulation. During an interview on 1/11/2024 at 8:25 a.m. with LVN 5, LVN 5 stated residents that were bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 19 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bound must be repositioned every 2 hours or as needed. LVN 5 stated residents were repositioned to prevent pressure on their skin. LVN 5 stated if residents were not repositioned it would increase the risk of skin breakdown/wounds. During an interview on 1/11/2024 at 11:02 a.m. with the DSD, the DSD stated CNAs were trained on what to look out for in residents when there was a change of condition. The DSD stated CNAs were instructed to observe residents for facial grimaces, body language, or anything out of the normal and report it to a nurse. The DSD stated CNA 2 should have reported Resident 85 was making loud noises when breathing. During an interview on 1/11/2024 at 12:29 p.m. with the Director of Nursing (DON), the DON stated CNAs were trained to observe residents and trained to notify any change of conditions to the charge nurse. The DON stated CNA 2 should have notified a licensed nurse that Resident 85's breathing was not normal. 2. During a review of Resident 35's admission Record, the admission record indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and peripheral vascular disease ([PVD] a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 35's History and Physical (H&P) dated 7/14/2023, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. The H&P indicated Resident 35 had a diagnosis of quadriplegia (paralysis [inability to move] that affects all the limbs and body from the neck down). During a review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/6/2023, the MDS indicated Resident 35's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 35's speech was unclear. The MDS indicated Resident 35 was dependent on staff for all activities of daily living (ADLs, self-care activities performed daily such as dressing, personal hygiene, grooming, and toilet use). The MDS indicated Resident 35 was at risk for a pressure ulcer/injury (injury to the skin and underlying tissue due to prolonged pressure). During a review of Resident 35's Care Plan for Skin, dated 8/30/2019, the care plan indicated Resident 35 was at risk for developing skin breakdown due to fragile skin, immobility, and history of skin alteration. The Care Plan indicated Resident 35's goal was to minimize the risk of skin breakdown/ bruising/pressure ulcer daily. The staff's interventions indicated to turn and position Resident 35 as needed when in bed or wheelchair. During an observation on 1/8/2024 at 12:19 p.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. During an observation on 1/8/2024 at 2:56 p.m., in Resident 35's room, Resident 35 was lying observed on his left side facing the door. During an observation on 1/9/2024 at 9:36 a.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 20 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0675 Level of Harm - Minimal harm or potential for actual harm During an observation on 1/9/2024 at 1:52 p.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. During an observation on 1/9/2024 at 3:21 p.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. Residents Affected - Few During an interview on 1/11/2024 at 10:48 a.m. with the Director of Staff Development (DSD), the DSD stated residents that had contractions, were weak and bedridden must get repositioned every 2 hours. The DSD stated residents were repositioned to prevent skin breakdown. The DSD stated CNAs received in-service training on repositioning residents and the CNAs should know that residents were to be repositioned every 2 hours. During an interview on 1/11/2024 at 12:17 p.m. with the DON, the DON stated bedridden resident should be repositioned every 2 hours and as needed. The DON stated CNAs have been told to reposition residents continuously throughout the day to prevent skin breakdown. The DON stated she expected all CNAs to assist all bedridden residents with repositioning at least every 2 hours to relieve skin pressure. The DON stated if residents did not get repositioned, they would be prone to skin breakdown and pain due to discomfort. During a review of the facility's policy and procedure (P&P) titled, Positioning/repositioning Residents, undated, the P&P indicated a pillow must be placed under the resident's upper arm to support it. The P&P indicated the upper leg must be bent, pillows must be placed under the thigh, calf, and foot for support. During a review of the facility's P&P titled, Change of Condition, undated, the P&P indicated its purpose was to ensure proper assessment and follow-through for any resident with a change condition. The P&P indicated a change of condition was a sudden or marked difference in residents: Vital signs (Temperature, pulse, heart rate, irregular pulse, shortness of breath). The P&P indicated all changes of condition in a resident shall be handled promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 21 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 74's admission Record, the record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). Residents Affected - Some During a review of Resident 74's H&P, dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's active physician orders, the orders indicated staff were supposed to administer a Lidocaine 5% patch to Resident 74's right lower back, once a day, for pain management, starting on 11/25/2023. During a review of Resident 74's care plans, the care plans indicated Resident 74 had a recent fracture. The goals of the care indicated Resident 74's pain would be managed and kept within a tolerable level. The staff's interventions indicated to administer pain medication as ordered by the physician. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., LVN 4 administered two medications to Resident 74. LVN 4 did not apply a Lidocaine 5% patch to Resident 74's right lower back. During a review of Resident 74's MAR, for the month of November 2023, the MAR indicated licensed staff documented Resident 74's Lidocaine 5% patch as administered on: 11/25/2023, 11/26/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/20/2023. The MAR indicated a total of six administrations of Resident 74's Lidocaine 5% patch for the month of 11/2023, by five different licensed nursing staff. During a review of Resident 74's MAR, for the month of December 2023, the MAR indicated licensed staff documented Resident 74's Lidocaine 5% patch as administered on: 12/1/2023, 12/2/2023, 12/3/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/7/2023, 12/8/2023, 12/9/2023, 12/10/2023, 12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/17/2023, 12/20/2023, 12/21/2023, 12/22/2023, 12/23/2023, 12/24/2023, 12/26/2023, 12/27/2023, 12/28/2023, and 12/31/2023. The MAR indicated a total of 24 administrations of Resident 74's Lidocaine 5% patch for the month of 12/2023, by seven different licensed nursing staff. During a review of Resident 74's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated LVN 4 documented Resident 74's Lidocaine 5% patch as administered on 1/9/2024. Further review of the MAR indicated other licensed staff documented the Lidocaine 5% patch as administered on: 1/1/2024, 1/2/2024, 1/3/2024, 1/4/2024, 1/5/2024, and 1/7/2024. The MAR indicated a total of 7 administrations of Resident 74's Lidocaine 5% patch for the month of 1/2024, by five different licensed nursing staff. During a concurrent observation and interview, on 1/9/2024 at 1:00 p.m., at Resident 74's bedside, Resident 74 rolled into a left-facing position in her bed. No Lidocaine 5% patch was observed to Resident 74's right lower back or displaced in Resident 74's bed linens. Resident 74 stated she did not receive the Lidocaine 5% patch that day and stated the patch had not been offered to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 22 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 1/9/2024 at 1:08 p.m., with LVN 5, LVN 5 opened the medication cart and removed the current inventory of Resident 74's Lidocaine 5% patches. LVN 5 stated the label affixed to the bag containing Resident 74's inventory of Lidocaine 5% patches was dated 11/24/2023 and indicated a total of 14 patches had been dispensed. LVN 5 stated there were two patches remaining in Resident 74's inventory. LVN 5 stated no additional patches had been requested or dispensed from the pharmacy. During an interview on 1/9/2024 at 1:44 p.m., with facility's contracted pharmacy, the pharmacy staff stated a total of 14 Lidocaine 5% patches had been dispensed to the facility on [DATE] for Resident 74. Pharmacy staff stated no refills had been requested or delivered. The pharmacy staff stated that when a medication was dispensed to the facility, the staff receiving the medication sign a receipt to confirm the medication was received. During a review of a document titled, Manifest: [Facility Name], dated 11/25/2023, the document indicated LVN 6 signed the document on 11/25/2023 at 4:14 a.m., confirming receipt of 14 Lidocaine 5% patches for Resident 74. During a concurrent record review and interview on 1/11/2024 at 3:35 p.m., with the Director of Nursing (DON), Resident 74's physician orders, MARs for 11/2023, 12/2023, 1/2024, and the Lidocaine 5% patch delivery records from the contracted pharmacy were reviewed. The DON stated medications were supposed to be administered as ordered by the physician. The DON stated only 14 Lidocaine 5% patches had been delivered to the facility, and stated there were not enough patches delivered to account for the 37 administrations documented from 11/25/2023 to 1/9/2024. The DON stated the medications had not been administered as ordered and stated that a resident's pain could go unaddressed if they did not receive their pain medication as ordered. During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated: a. Medications are administered in accordance with written orders of the attending physician. b. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for two of 23 sampled residents (Resident 74 and 297) when the following occurred: 1. Licensed staff failed to complete a 72-hour neurological check (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) as ordered by the physician and as indicated within the facility's policy after Resident 297, who was admitted to the facility with a history of a fall which resulted in a subdural hemorrhage (bleeding in the area between the brain and the skull), had another fall (in the facility) with head trauma (physical injury). 2. Licensed staff documented thirty-seven (37) administrations of Lidocaine 5% patch (medicated patch applied to the skin for pain management) for Resident 74, when only fourteen (14) patches had been dispensed to the facility. These deficient practices had the potential to result in a missed assessment that could have led to an undetected, repeated subdural hemorrhage, which could have resulted in severe neurological (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 23 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0684 (brain) impairment or death for Resident 297, and created the potential for Resident 74 to experience avoidable harm from pain related to non-administered pain medication. Level of Harm - Minimal harm or potential for actual harm Cross Reference: F-tag 726, F-tag 759, and F-tag 760 Residents Affected - Some Findings: 1. During a review of Resident 297's admission Record, the admission Record indicated Resident 297 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage, malignant neoplasms (cancerous growths) of the lung, and history of falling. During a review of Resident 297's History and Physical (H&P), dated 1/3/2024, the H&P indicated Resident 297 had the capacity to understand and make decisions. During a review of Resident 297's care plan titled, Actual Fall, initiated 1/7/2024, the care plan indicated Resident 297 had an actual fall related to balance deficit (difficulty), decreased strength and endurance (the body's physical capability to sustain an exercise for an extended period), history of falls, and unsteady gait (ability to walk). The staff's interventions were to conduct a neurological assessment for 72 hours. During a review of Resident 297's Change of Condition (COC) Form, dated 1/7/2024, the COC form indicated Resident 297 had an unwitnessed fall and staff found Resident 297 lying on his back. The note indicated Resident 297 stated that he tried to get up to use the restroom . slipped, and fell to the floor, hitting the posterior of his head. During a review of Resident 297's Order Summary, dated 1/9/2024, the Order Summary had indicated the facility was to perform a neurological check for 72 hours for an unwitnessed fall from 1/7/2024 to 1/10/2024. During a concurrent review and interview, on 1/8/2024, at 3:58 p.m., with Licensed Vocational Nurse (LVN) 7, the 72 Hours Neuro- Check List, dated 1/7/2024 to 1/8/2024 was reviewed. LVN 7 verified the neurological check list indicated the section where Resident 297's vital signs and neurological function (blood pressure, temperature, pulse, respiratory rate, level of consciousness, the left and right pupils, left and right-hand grips) were to be documented had been left blank for the hours of 12:30 a.m., 4:30 a.m., 8:30 a.m., and 12:30 p.m. on 1/8/2024. LVN 7 stated the form was incomplete, and it should have been completed to indicate and ensure Resident 297's neurological function was intact. LVN 7 stated the importance of completing the form and documenting in real time was to ensure no assessments were missed and that Resident 297 did not experience signs of an internal brain bleed. During a concurrent review and interview, on 1/8/2024, at 4:10 p.m., with the Infection Prevention Nurse (IPN), the 72 Hours Neuro- Check List, dated 1/7/2024 to 1/8/2024 was reviewed. The IPN verified the neurological check list indicated the section where Resident 297's vital signs and neurological function were to be documented was left blank for the hours of 12:30 a.m., 4:30 a.m., 8:30 a.m., and 12:30 p.m. on 1/8/2024. The IPN stated the form should have been completed and that if vitals were not taken, there would be a possibility the nurses would have missed an important change in Resident 297's condition, or a neurological assessment that could have indicated an internal brain bleed. During a concurrent review and interview, on 1/11/2024, at 1:47 p.m., with the Director of Nursing (DON), the 72 Hours Neuro- Check List, dated 1/7/2024 to 1/8/2024, was reviewed. The DON verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 24 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the neurological check list indicated the section where Resident 297's vital signs and neurological function were to be documented was left blank for the hours of 12:30 a.m., 4:30 a.m., 8:30 a.m., and 12:30 p.m. on 1/8/2024. The DON stated the sheet had not been complete and should have been complete so that the nurses can properly assess the resident. The DON stated that there was a potential for the nurses to have missed an assessment, like a spike in the resident's blood pressure, unrelieved pain, and signs of a hemorrhage. During a review of the facility's policy and procedure (P&P) titled, Incidents and Accidents (undated), the P&P indicated the facility was to ensure vital signs are taken with neurocheck[s] on any head injury for 72 hours (use of Neurocheck form). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 25 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure precautions were maintained to prevent the development of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for one of five sampled residents (Resident 73) by failing to: Residents Affected - Few 1. Ensure Resident 73's weight was accurately set on the low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). These failures had the potential to result in the development of skin breakdown and/or pressure ulcers which could result in complications associated with impaired skin integrity for Residents 73. Findings: During a review of Resident 73's admission record, the record indicated the facility originally admitted Resident 73 on 7/29/2022 and re-admitted Resident 73 on 10/14/2023. Resident 73's admitting diagnoses included abnormal posture, generalized muscle weakness, and lack of coordination. During a review of Resident 73's progress note by Registered Nurse (RN) 1, dated 9/28/2023, the progress note indicated New orders for low air loss mattress [LALM] for wound [management] and prevention per [Medical Doctor] noted and carried out. During a review of Resident 73's medical record titled Wound Risk Assessment, dated 10/14/2023, the record indicated Resident 73 was at high risk for skin breakdown based on her medical conditions, and indicated Resident 73 was willing to participate in the plan of care for wound management. During a review of Resident 73's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a review of Resident 73's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 12/26/2023, the MDS indicated Resident 73 experienced cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 73 required partial to moderate assistance from staff when rolling from her back to a side-lying position in bed and was fully dependent on staff assistance to transition from a sitting position to a lying position, and a lying position to a sitting position. The MDS further indicated Resident 73 was at risk for developing PUs. During a review of Resident 73's care plans, the care plans indicated Resident 73 was at risk for developing PUs, and goals of care included reducing Resident 73's risk of experiencing skin breakdown/PUs through appropriate interventions. Staff's interventions indicated to ensure skin treatments and management as ordered. During an observation, on 1/8/2023 at 10:34 a.m., at Resident 73's bedside, Resident 73 was observed lying on a Proactive brand Protekt Aire 4000DX/5000DX Low air loss mattress (LALM). The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 280 pounds (lbs., a unit of measuring weight). During an observation, on 1/10/2023 at 9:16 a.m., at Resident 73's bedside, Resident 73 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 26 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observed lying on a Proactive brand Protekt Aire 4000DX/5000DX LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 280 lbs. During a concurrent interview and record review, on 1/10/24 at 9:42 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 73's monthly weight measurements for 1/2024. LVN 1 stated Resident 73's records indicated Resident 73 weighed 141.0 lbs. on 1/2/2024. LVN 1 stated she was responsible for adjusting the LALM settings. LVN 1 stated resident 73's LALM settings had not been changed within the last few months. During a concurrent observation and interview, on 1/10/2024 at 9:49 a.m., at Resident 73's bedside, with Licensed Vocational Nurse (LVN) 1, LVN 1 observed the LALM Resident 73 was lying on. LVN 1 stated Resident 73's LALM was set for a resident that weighed 280 lbs. LVN 1 stated the settings for Resident 73's LALM were not correct. LVN 1 stated it was important to ensure the weight settings were correct to ensure the pressure to Resident 73's skin was offloaded effectively. LVN 1 stated that incorrect settings increased risk for the resident to develop a PU. During an interview on 1/11/2024 at 1:09 p.m., with the Director of Nursing (DON), the DON stated the air in the LALM was used to relieve pressure on the skin. The DON stated LALMs were used for PU prevention in residents who were at high risk for developing PUs. The DON stated it was important to ensure the weight settings were correct to ensure accurate pressure in the mattress and stated facility staff were supposed to use and operate the mattress according to the manufacturer's guidelines. During a review of the facility policy and procedure (P&P) titled, Pressure Sore Management, undated, the P&P indicated all available measures shall be taken to reduce skin breakdown and pressure [ulcers] and that individual care plans for management of skin condition would be developed as indicated. During a review of the facility document titled, Proactive Medical Products Operation Manual for Protekt Aire 4000DX/5000DX, undated, the document indicated facility staff were supposed to press the up/down buttons on panel to adjust the weight/pressure level to the patient's specific requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 27 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments and services to two of seven sampled residents (Residents 27 and 82) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move) when the facility failed to: 1. Provide ROM services for Resident 27 to improve or prevent a decline in both of Resident 27's arms. 2. Provide Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and mobility) ambulation (walking) exercise five times a week as ordered for Resident 82. These deficient practices had the potential to cause residents to have a decline in mobility (ability to move), lead to contractures (loss of motion of a joint), and have a decline in physical functioning such as the ability to eat, dress, and walk. Findings: 1. During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 7/17/2023 with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones), muscle weakness, and neuropathy (nerve damage). During a review of Resident 27's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) admission Rehabilitation Screening, dated 7/18//2023, the OT admission rehabilitation screening indicated Resident 27 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms (shoulder, elbow, wrist, hand). During a review of Resident 27's OT Joint Mobility Screening, dated 7/18/2023, the OT joint mobility screening indicated Resident 27 had full ROM in both wrists, both hands, both elbows, and severe (>50% loss) ROM limitations in both shoulders and recommended Resident 27 be evaluated by OT. During a review of Resident 27's OT Evaluations and Plan of Treatment, dated 7/18/2023, the OT evaluations and plan of treatment indicated Resident 27 had ROM impairments (state of being weakened or damaged) in both shoulders and had decreased strength in both shoulders, both elbows, both wrists, and both hands. During a review of Resident 27's Minimum Data Set (MDS, an assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 27 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 27 required extensive assistance for bed mobility and eating and total assistance for transfers (moving from one surface to another), locomotion (ability to move from one place to another) on and off the unit, dressing, personal hygiene, and toilet use. The MDS indicated Resident 27 had no functional limitations in ROM in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 28 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 27's OT Discharge summary, dated [DATE], the OT discharge summary indicated Resident 27 was discharged per case manager with no recommendation for RNA services because Resident 27 was able to move both arms actively and independently. During a review of Resident 27's Order Summary Report, the order summary report indicated for RNA to perform passive ROM exercises (PROM, movement at a given joint with full assistance from another person) to Resident 27's both legs. During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 required substantial/maximal assistance for eating, oral hygiene, toilet hygiene, and bathing and total assistance in dressing and personal hygiene. The MDS indicated Resident 27 had functional ROM limitations in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's OT Rehabilitation Screen, dated 10/20/2023, the OT rehabilitation screen indicated OT recommended an RNA program to prevent a decline in function. During a review of Resident 27's Order Summary Report, the order summary report did not include an RNA order for ROM to Resident 27's arms. During a concurrent observation and interview with Resident 27 on 1/9/2024 at 9:52 a.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the entire body. Resident 27 stated she had pain all over her body and requested pain medication. Resident 27 stated she has had more pain on the left side of the body for years and stated it was hard to move the left wrist and left shoulder. Resident 27 was unable to bring both arms overhead and was unable to make a full fist with both hands. Resident 27 stated she wished staff would assist with ROM exercises to both arms because they were painful and hard to move on her own. During a concurrent observation and interview on 1/9/2023 at 2:20 p.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the body. Resident 27 stated she felt much better because she was in less pain and removed the blanket from the upper half of the body using both arms. Resident 27 moved both arms to shoulder level and bent and straightened both elbows. Resident 27 was able to make 90% of a full fist with both hands, bent the left wrist downwards, and had difficulty moving left wrist upwards due to pain. Resident 27 stated she was able to feed herself and wash her face once nursing assisted with set-up. During an interview on 1/10/2024 at 10:02 a.m., Restorative Nursing Aide 1 (RNA 1) stated she provided PROM exercises to Resident 27's legs and did not provide ROM exercises to the arms. RNA 1 stated Resident 27 frequently asked RNA to assist with arm exercises, but RNA 1 was unable to because the RNA order indicated to provide exercises to both legs only. RNA 1 stated she informed the Director of Rehabilitation (DOR) and the Director of Nursing (DON) in a weekly meeting about Resident 27's request for arm exercises, but the DOR stated Resident 27 did not need assistance with arm exercises. During a follow up interview on 1/10/2024 at 2:45 p.m., RNA 1 stated she felt Resident 27 could benefit from RNA services for arm exercises because Resident 27 frequently requested assistance with arm exercises and had the potential to do more for herself if her arms were stronger and moved better. During a concurrent interview and record review on 1/10/2024 at 2:08 p.m., with the MDS Nurse (MDSN), Resident 27's MDS (dated 7/21/2023 and 10/19/2023), physician's orders, and care plan were reviewed. The MDSN confirmed Resident 27 had a decline in ROM to both arms and both legs according to the MDS. The MDSN stated Resident 27 was unable to demonstrate she was able to perform her activities of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 29 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some daily living (ADLs, basic activities such as eating, dressing, and toileting) using her arms during the MDS assessment on 10/19/2023 primarily because she was uncooperative. The MDSN stated an Interdisciplinary Team (IDT, group of different disciplines working together for a common goal of a resident) meeting should have been initiated to ensure interventions were developed and implemented to address the limitations once the decline in ROM of Resident 27's arms and legs were identified but was not done. The MDSN stated Resident 27 should have been on therapy or RNA services to address the decline in ROM of both arms identified in the MDS but was not. The MDSN confirmed RNA services were ordered for PROM of both legs but was not ordered for the arms. The MDSN confirmed there were no interventions in place to address the change in ROM or prevent a further decline in ROM of Resident 27's arms. The MSDN stated Resident 27 was at risk for contractures because she did not get out of bed, required assistance with ADLs, and needed a lot of encouragement to participate in everyday activities. During a concurrent interview and record review on 1/10/2024 at 2:47 p.m., with the Director of Rehabilitation (DOR) who was an Occupational Therapist (OT), Resident 27's OT notes, Rehabilitation screens, joint mobility screen, and physician's orders were reviewed. The DOR stated she did not write an RNA order for arm exercises because Resident 27 was able to use both arms for ADLs during the Rehabilitation Screening but required a lot of encouragement due to guarded and self-limiting behavior. The DOR stated nursing and RNA reported Resident 27 had been increasingly asking for assistance for care that required the use of the arms but felt that issue was more related to Resident 27's behavior rather than physical abilities. The DOR stated she was unaware nursing identified Resident 27 as having a decline in arm ROM in the MDS. The DOR stated the decline in Resident 27's arm ROM should have been communicated to the rehab department in an IDT meeting but was not. The DOR stated RNA arm exercises should have been ordered when nursing staff identified the functional decline in the MDS, at the time of the Rehabilitation Screening since Resident 27 required encouragement to use both arms for ADLs, and when Resident 27 requested arm exercises from RNA, but was not. The DOR stated Resident 27 was at high risk for contracture development and a functional decline because Resident 27 had a diagnosis of osteoarthritis, required assistance with mobility and ADLs, and required encouragement to move on her own. During a concurrent interview and record review on 1/11/2024 at 2:38 p.m., with the Director of Nursing (DON), Resident 27's IDT notes, MDS assessments, care plan, and physician's orders were reviewed. The DON confirmed Resident 27's had a decline in both arm ROM according to the MDS assessments. The DON confirmed Resident 27 did not have a care plan, interventions, and any services in place to address the decline in Resident 27's arm ROM. The DON stated residents with ROM impairments should be on therapy or RNA services to prevent a decline in function. The DON stated an IDT meeting should have been done, a care plan should have been created, and interventions should have been implemented once Resident 27's arm ROM decline was identified on the MDS but was not. The DON stated Resident 27 was at risk for contracture development and a functional decline because there were no interventions in place improve or prevent a decline in Resident 17's arm ROM. 2. During a concurrent observation and interview on 1/11/2024 at 2:05 p.m., in Resident 82's room, Resident 82 was observed sitting at the edge of the bed wearing a right leg prosthesis (artificial device used to replace a missing or impaired part of the body). A cane (mobility device used for walking) and wheelchair were observed next to the bed. Resident 82 stated he needed help putting on and taking off the right leg prosthesis, was able to walk short distances with a cane, and used a wheelchair for mobility when he got tired from walking. During a review of Resident 82's admission Record, the admission Record indicated the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 30 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some initially admitted Resident 82 on 5/2/2023 and re-admitted the resident on 6/12/2023 with diagnoses including peripheral vascular disease (reduced circulation of blood to a body part due to a narrowed or blocked blood vessel) and acquired absence of the right leg below the knee (amputation of the leg below the level of the knee). During a review of Resident 82's MDS dated [DATE], the MDS indicated Resident 82 was cognitively intact. The MDS indicated Resident 82 required supervision or touching assistance for eating, dressing, oral hygiene, toileting hygiene, bathing, rolling, and transfers and partial/moderate assistance for walking ten feet. The MDS indicated Resident 82 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) on one leg (hip, knee, ankle, foot). During a review of Resident 82's Order Summary Report, the order summary report indicated for RNA to perform walking exercises with Resident 82 on an even surface using crutches (mobility device used to provide support while walking), five times a week. During a review of Resident 82's RNA flowsheets for December 2023, the RNA flowsheets indicated for the RNA to perform walking exercises with Resident 82 on an even surface using crutches, five times a week. The squares on the RNA flowsheet were blank on the following days: 12/8/2023, 12/11/2023, 12/14/2023, 12/18/2023, and 12/21/2023. During a concurrent interview and record review on 1/11/2024 at 9:26 a.m., with the Director of Staff Development (DSD), Resident 82's RNA December 2023 flowsheets and physician's orders were reviewed. The DSD confirmed Resident 82 had physician orders for RNA to provide RNA services five times a week. The DSD stated a blank square on the RNA flowsheet grid indicated the resident was not seen for RNA treatment that day. The DSD confirmed Resident 82 missed five days of scheduled RNA services for the month of December. The DSD stated Residents 82 did not receive RNA treatments as ordered by the physician. The DSD stated it was important for RNA to provide services as prescribed by the physician because missed treatments could place residents at risk for a functional decline. During an interview on 1/11/2024 at 2:28 p.m., with the Director of Nursing (DON), the DON stated the purpose of the RNA program was to maintain a resident's current level of function. The DON stated missed RNA treatments could potentially cause a resident to experience a decline in overall function, mobility, and ADLs. During a review of the facility's undated Policy and Procedure (P&/P), titled Restorative Nursing Program, the P&P indicated the purpose of the RNA program was to maintain the resident's functional abilities and to reduce further declines. The P&P indicated each resident would be given care to reduce the risk of pressure sore (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) formations, contractures, deformities (disfigured), and a decline in functional activities that include ROM exercises, strengthening, and ambulation activities. During a review of the facility's undated P&P, titled Joint Mobility Contracture Management Program, the P&P indicated the purpose of the facility's Contracture Management Program was to reduce contractures in the arms and legs and to promote function and skin integrity. The P&P indicated all resident's ROM was to be assessed and reviewed quarterly by the nursing staff. Any ROM changes or concerns were to be noted, therapy interventions for a ROM program would be recommended, appropriate physician's orders would be obtained by nursing, a care plan would be developed, and the recommended ROM program would be implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 31 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 interview and record review, the facility failed to ensure fall precautions were maintained for two of five sampled residents (Resident 22 and Resident 73) when the following occurred: 1. Resident 22 did not have fall mats placed at her bedside, and call light was not within her reach. 2. Resident 73 did not have a fall mat placed at her bedside. These failures had the potential to cause avoidable harm to Resident 22 and Resident 73 related to repeat falls and the potential injuries related to sustaining a fall. Findings: 1. During a review of Resident 22's admission Record, the admission record indicated the facility originally admitted Resident 22 on 12/5/2015 and re-admitted Resident 22 on 8/13/2021. Resident 22's admitting diagnoses included osteoarthritis (wearing down of the protective tissue at the ends of bones that occurs gradually and worsens over time), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), aphakia in both eyes (not having a lens inside the eye, causing lack of focus and blurry vision), difficulty walking, and generalized muscle weakness. During a review of Resident 22's History and Physical (H&P), dated 8/30/2023, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 12/14/2023, the MDS indicated Resident 22 experienced severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 22 also exhibited inattention and disorganized thinking. The MDS indicated Resident 22 required partial to moderate assistance from staff when rolling in bed from her back to a side-lying position, transitioning from a sitting position to lying position and vice versa, and transferring between surfaces (chair to bed and vice versa, on and off the toilet, and in and out of the shower). During a review of Resident 22's medical records, the records indicated Resident 22 sustained two falls in the facility on 10/26/2021 and 2/26/2022. During a review of Resident 22's medical record titled, Fall Risk Assessment, dated 12/14/2023, the record indicated Resident 22 was high risk for falls. The record indicated staff were required to develop a care plan to reduce falls and injuries. During a review of Resident 22's care plans regarding falls, the care plans indicated Resident 22 was at risk for falls and injury. The goals of care included a reduction of the risk for falls and injury daily. Staff's interventions indicated to place floor mats at the bedside and keep the call light within easy reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 32 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 During a review of Resident 22's physician orders, dated 5/26/2023, the orders indicated staff were to place floor mats at Resident 22's bedside to decrease potential injury. During an observation on 1/8/2024 at 11:22 a.m., at Resident 22's bedside, Resident 22 was observed lying at the foot-end of her bed, with a gap of two (2) feet between her head and the headboard. Resident 22's legs were dangling at the right edge of the bed. Resident 22's call light was at the head of the bed and not within reach. No fall mats observed to either side of the bed. During an observation on 1/11/2024 at 10:45 a.m., at Resident 22's bedside, Resident 22 was observed lying in bed. Call light was not observed in Resident 22's bed or placed near Resident 22. During a concurrent observation and interview, on 1/11/2024 at 10:53 a.m., at Resident 22's bedside, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 22 had a history of falls and was high risk for repeat falls. LVN 2 stated Resident 22 tended to get out of bed without assistance and required fall mats for injury prevention. LVN 2 stated Resident 22's call light was on the floor behind Resident 22's bed, and out of Resident 22's reach. 2. During a review of Resident 73's admission Record, the record indicated the facility originally admitted Resident 73 on 7/29/2022 and re-admitted Resident 73 on 10/14/2023. Resident 73's admitting diagnoses included left knee osteoarthritis, abnormal posture, generalized muscle weakness, and lack of coordination. During a review of Resident 73's H&P, dated 11/2/2023, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73 experienced cognitive impairment. The MDS indicated Resident 73 required partial to moderate assistance from staff when rolling from her back to a side-lying position in bed and was fully dependent on staff assistance to transition from a sitting position to lying position, and a lying position to a sitting position. The MDS further indicated Resident 73 required substantial to maximal assistance with performing hygiene activities, getting dressed, and bathing. During a review of Resident 73's medical records, the records indicated Resident 73 sustained a fall on 9/15/2023. Resident 73's radiology report, dated 9/15/2023, indicated Resident 73 sustained a proximal right humerus fracture (broken arm bone) and swelling of the soft tissue (muscles, fat, blood vessels, nerves, tendons, and tissues that surround the bones and joints). The records further indicated Resident 73 was hospitalized from [DATE] to 9/22/2023. During a review of Resident 73's medical record titled, Fall Risk Assessment, dated 9/15/2023, the record indicated Resident 73 sustained a change of condition and was high risk for falls. The record indicated staff were required to develop a care plan to reduce falls and injuries. During a review of Resident 73's care plans regarding falls, the care plans indicated Resident 73 was at risk for falls and injury. The goals of care included a reduction of the risk for falls and injury daily. During a review of Resident 73's physician orders, dated 10/14/2023, the orders indicated staff were supposed to keep Resident 73's bed in a low position with a floor mat at the bedside to decrease potential injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 33 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 During a concurrent observation and interview, on 1/8/2024 at 10:32 a.m., with Resident 73 at Resident 73's bedside, Resident 73 observed with a sling to her right arm. Resident 73 stated she had sustained a fall in the facility. Resident 73 stated that following the fall, staff placed a fall mat at her bedside, and could not state when the mat was removed. Resident 73 stated it had been gone a while. No fall mat observed at Resident 73's bedside. Residents Affected - Few During an interview on 1/10/2024 at 11:01 a.m., with LVN 3, LVN 3 stated fall mats were for prevention of injury related to falls. LVN 3 stated that if a resident has orders for fall mats, and they are indicated in the care plan, and the floor mats should be at the resident's bedside. LVN 3 stated the facility had enough floor mats to ensure that all residents who require them have them available. LVN 3 stated not having fall mats at the bedside could increase the potential for injury if a resident sustained a fall. LVN 3 stated a resident could fall and sustain a broken bone. During an interview on 1/11/2024 at 1:13 p.m., with the Director of Nursing (DON), the DON stated fall precautions and interventions should be implemented when assessments indicate the resident is at risk for falls. The DON stated the purpose of fall mats was to reduce injury if a resident were to fall. The DON also stated the purpose of a call light was to allow residents to call for help when needed, and stated the call light should always be within the resident's reach. The DON stated the call light should not be on the floor behind the resident's bed. The DON stated that failure to implement the fall prevention interventions on a resident's care plan, or as ordered, increased the risk for residents to sustain falls and injury. During a review of the facility's policy and procedure (P&P) titled, Promoting Safety, Reducing Falls, undated, the P&P indicated major risk factors for falls included a history of falls, and intrinsic factors such as the age of a resident, vision losses, and medical conditions such as neurological deficits, and gait and balance disturbances. The P&P further indicated that staff were supposed to keep call-lights within easy reach of residents. During a review of the facility's P&P titled, The Resident Care Plan, undated, the P&P indicated the nursing care plan acts as a communication instrument between nurses and other disciplines. The P&P further indicated the resident care plan shall be implemented for each resident and it is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 34 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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** The facility failed to ensure the resident's nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) and the oxygen concentrator humidifier bottle (medical devise that increases the humidity in the nostrils while using supplemental oxygen) were labeled with the date, time, and initials of the nurse when initially used for Resident 10 and Resident 51. Residents Affected - Few This deficient practice had the potential to cause a negative respiratory outcome and increased the risk for Resident 10 and Resident 51 to acquire a respiratory infection. Findings: 1. During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood). During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/19/2023, the MDS indicated Resident 10 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 10's cognition (process of thinking) was severely impaired. During a review of Resident 10's History and Physical (H&P), dated 3/13/2023, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report, dated 1/7/2024, the Order Summary Report indicated to administer oxygen at two (2) liters (unit of measurement) per minute (L/min) via nasal cannula, may titrate (change rate) up to five L/min for oxygen saturation (amount of oxygen circulating in the blood, normal value 95% to 100%) less than 95%. The Order Summary Report indicated to change the humidifier and nasal cannula every Sunday during the night shift. During an observation on 1/8/2024 at 9:15 a.m., in Resident 10's room, Resident 10 was receiving 2 L/min of oxygen. Resident 10's oxygen concentrator humidifier bottle was dated, 1/8/2024, and the nasal cannula tubing did not have a label. During an observation on 1/9/2024 at 1:55 p.m., in Resident 10's room, Resident 10 was receiving 2 L/min of oxygen. Resident 10's oxygen concentrator humidifier bottle was dated, 1/8/2024, and the nasal cannula tubing did not have a label. During an observation on 1/11/2024 at 7:43 a.m., in Resident 10's room, Resident 10 was receiving 2 L/min of oxygen. Resident 10's oxygen concentrator humidifier bottle was dated, 1/8/2024, and the nasal cannula tubing was dated, 1/10/2024. During an interview on 1/11/2024 at 7:51 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the nurses had to label the nasal cannula and humidifier bottle with the date and time it was opened. LVN 3 stated the nasal cannula and humidifier bottles were to be changed every week or as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 35 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN 3 stated dating these items ensured that they would not be used past the date because using the nasal cannula and humidifier bottle longer than ordered could be an infection control issue. LVN 3 stated if the nasal cannula and humidifier bottle were not dated, the staff would be unsure when they were opened and should be thrown away. LVN 3 stated there was a potential for the nasal cannula and humidifier bottle to be used longer than intended if they were not dated and that could lead to infection from growth of bacteria that could enter through the nose and into the body. During an interview on 1/11/2024 at 9:48 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the nasal cannulas and humidifier bottles were changed weekly but could be changed more frequently. The IPN stated the labels on the nasal cannula and humidifier bottle would notify the nurses if they were old and if they needed to be changed. The IPN stated germs and bacteria could develop in the tubing over time and if those germs and bacteria were to be administered to the resident, they could become sick. During a concurrent interview and record review on 1/11/2024 at 12:02 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, was reviewed. The P&P indicated, The date, time, and initials should be noted on oxygen equipment when it is initially used and when changed. The DON stated the nasal cannula, humidifier bottle, and any other oxygen equipment used for the residents must be labeled with the date, time, and initials when initially opened and changed. The DON stated if the equipment were not labeled correctly, the nurse must remove them and change with a brand-new set. The DON stated without the label, the equipment could be used for an unknown duration of time and organisms could develop inside. The DON stated oxygen was administered directly into the residents' nose and when they inhale, they could potentially inhale harmful organisms that could make them sick. 2. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid) and pulmonary hypertension (a condition that affects the blood vessels in the lungs which develops when the blood pressure in your lungs is higher than normal). During a review of Resident 51's Order Summary report, dated 8/27/2023, the Order Summary Report indicated Resident 51 had an order for oxygen therapy at 2 L/min via nasal cannula. During a review of Resident 51's H&P dated 8/28/2023, H&P indicated Resident 51 had the capacity to understand and make decisions. During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 51 required substantial assistance (staff does more than half the effort) for personal hygiene and toileting hygiene and required set up assistance for eating. During an observation on 1/8/2024 at 11:18 a.m., in Resident 51's room, Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an observation on 1/9/2024 at 8:08 a.m., in Resident 51's room, Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 36 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 1/10/2024 at 7:46 a.m., in Resident 51's room, the Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an observation on 1/11/2024 at 2:56 p.m., in Resident 51's room, Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an interview on 1/10/2024 at 10:15 a.m. with LVN 2, LVN 2 stated oxygen equipment must be dated when it was opened. LVN 2 stated oxygen equipment was dated to prevent infections. During an interview on 1/11/2024 at 11 a.m. with the Director of Staff Development (DSD), the DSD stated nasal cannulas should be changed weekly. The DSD stated the nasal cannula must be labeled with the date and the nurses' initials. The DSD stated it was important to date the nasal cannulas to know how old the nasal cannula was and served as an infection control measure. During an interview on 1/11/2024 at 12:03 p.m. with the DON, the DON stated the nasal cannula should be changed every 7 days. The DON stated the nasal cannula must be labeled with the date and the time the nasal cannula was opened and with the initials of the nurse that set up the oxygen administration. The DON stated if a nurse noticed an undated nasal cannula, the nurse must get rid of it and place a new one because there was no way of knowing how old the nasal cannula was. The DON stated it was important to date the nasal cannula to prevent using an old nasal cannula because it had the potential to cause an infection because it went directly into the resident's nose. During a review of facility's P&P titled, Oxygen Administration, undated, the P&P indicated the date, time and initials should be noted on oxygen equipment when it is initially used and when changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 37 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 interview and record review, the facility failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) treatment was assessed before and after dialysis treatment and the assessment was documented in the Dialysis Communication Records for one of one sampled resident (Resident 81). Residents Affected - Few This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding, and bruising. Findings: During a review of Resident 81's admission Record, the admission record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including dependence on renal dialysis and end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 81's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/25/2023, the MDS indicated Resident 81's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 81 required assistance with setup or cleanup for eating, and required supervision or touching assistance for oral hygiene, toileting hygiene and personal hygiene. The MDS indicated Resident 81 had a diagnosis of diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 81's History and Physical (H&P) dated 12/15/2023, the H&P indicated Resident 81 was not able to make his own decisions but was able to make needs known. During a review of Resident 81's Order Summary Report dated 12/15/2023, the order summary report indicated to monitor Resident 81's dialysis access site (right upper chest) for pain, itching, bleeding, and swelling on every shift. During a review of Resident 81's Dialysis Communication Records, for the months of December 2023 and January 2024, indicated the pre-dialysis assessment and post dialysis assessment were inaccurately performed or were not performed, under the following sections on the following dates: On 12/18/2023 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's graft (access) site location was on the right forearm. The record indicated Resident 81 did not have a central line and indicated Resident 81's access site was not checked for bleeding. On 12/20/2023 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's graft site location was on the right forearm. The record indicated Resident 81's access site was not checked for bleeding. On 12/22/2023 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's graft site location was on the right forearm. The record indicated Resident 81 did not have a central (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 38 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 line. Level of Harm - Minimal harm or potential for actual harm On 12/27/2023 - The pre dialysis assessment indicated Resident 81's graft site was on the right arm. Residents Affected - Few On 12/29/2023 - The pre dialysis assessment indicated Resident 81 did not have a central line. The post dialysis assessment indicated the central line section was not addressed. On 1/3/2024 - The record indicated Resident 81's access site was not checked for bleeding pre and post dialysis treatment. On 1/5/2024 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's access site was not assessed. The record indicated Resident 81's access site was not checked for bleeding post dialysis treatment. On 1/10/2024 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's access site location was on the right forearm. In the pre dialysis assessment and post dialysis assessment the access site was not assessed. The record indicated Resident 81's access site was not checked for bleeding pre and post dialysis treatment. During an interview on 1/8/2024 at 2:33 p.m. with Resident 81, in Resident 81's room, the Resident 81 stated he received dialysis treatment through his right perma catheter (a flexible tube placed into the blood vessel in your neck or upper chest and is threaded to the right side of the heart). Resident 81 stated he used to get dialysis treatment to his right arm but it was not working. Resident 81 stated he had to keep reminding the nurses that his dialysis treatment was done through his chest and not his arm. During an interview on 1/11/2024 at 4:02 p.m. with Director of Nursing (DON), the DON stated she expected nursing staff to assess residents before they leave for dialysis treatment. The DON stated she expected nurses to take the residents vital signs, and assess the dialysis access site for bleeding, redness and pain before the residents leave to dialysis treatment. The DON stated she expected nurses to assess the residents when they returned from dialysis treatment. The DON stated nurses must assess the resident's cognitive status, assess the access site for bleeding, redness, and pain, and check for a bruit (an audible vascular sound associated with turbulent blood flow) and thrill (an abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula) if applicable. The DON stated she expected nurses to completely fill out the dialysis communication record. The DON stated assessing residents pre and post dialysis was a preventive measure and it must be done. During a review of the facility's policy and procedure (P&P) titled, Care of Resident Receiving Renal Dialysis, undated, the P&P indicated a Dialysis Communication record must be completed during dialysis days. The P&P indicated to send the form with the resident to dialysis and complete the post dialysis section when the resident returns from dialysis. The P&P indicated a complete pre-dialysis assessment includes cognitive status, vital signs, access site (central line, shunt, graft site), document presence or absence of bruit and/or thrill, bleeding at site, and breathing patterns/breathing sounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 39 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to perform a competency assessment for Licensed Vocational Nurse (LVN) 4 upon hire as per the facility's policy and procedure (P&P), which resulted in LVN 4 failing to competently administer medications and supplements as ordered by the physician for three out of five sampled residents (Resident 81, 74, and 7), including one significant medication administration error, during the medication administration observations. This deficient practice had the potential to place Resident 81, 74, and 7, and other residents at risk for harm related to improper administration of medication, and delays in provision of care related to missed administrations of ordered medications and supplements. Cross Reference: F-tag 726, F-tag 760, and F-tag 684 Findings: 1. During a review of Resident 81's admission Record, the record indicated the facility originally admitted Resident 81 on 7/29/2022 and re-admitted Resident 81 on 12/15/2023. Resident 81's admitting diagnoses included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (a treatment for people whose kidneys are failing), type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood, creating risk of heart attack and stroke). During a review of Resident 81's History and Physical (H&P), dated 12/15/2023, the H&P indicated Resident 81 did not have the capacity to make his own decisions. During a review of Resident 81's Physician Orders, dated 12/15/2023, the orders indicated staff were to administer a total of seven (7) medications and four (4) supplements at 9:00 a.m. on 1/9/2024. During an interview on 1/9/2024 at 8:20 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she was preparing to administer medications for Resident 81 and had not administered any medications yet. During a concurrent observation and interview on 1/9/2024 at 8:34 a.m., outside of Resident 81's room, LVN 4 confirmed a total of three (3) medications were being administered to Resident 81. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 81's room and Resident 81 took all three (3) medications with water. The three medications administered were Labetalol HCl (used to treat high blood pressure), Amlodipine besylate (used to treat high blood pressure), and hydralazine HCl (used to treat high blood pressure). LVN 4 did not offer or administer any further medications or supplements to Resident 81. During a concurrent observation and interview on 1/9/2024 at 8:41 a.m., outside of Resident 81's room, with LVN 4, LVN 4 prepared one (1) injection of Lantus (insulin glargine, a medication for controlling blood sugar levels) for Resident 81 and confirmed a total of one (1) medication was to be administered. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 81's room and Resident 81 refused the insulin glargine administration. LVN 4 exited the room with the one (1) unadministered medication and returned the medication to the medication cart. LVN 4 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 40 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0726 offer or administer any further medications or supplements to Resident 81. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 81's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated LVN 4 documented she had administered six (6) medications and four (4) supplements scheduled for the 9 a.m. administration. There were four (4) medications and four (4) supplements documented as administered by LVN 4 that were not observed as administered. Hydralazine HCl was administered at 8:34 a.m. by LVN 4 was not documented on the MAR. The MAR further indicated the Hydralazine HCl was supposed to be given at 6 a.m. Residents Affected - Few During a concurrent interview and record review on 1/10/2024 at 10:30 a.m., with LVN 5, Resident 81's progress notes and MAR for the month of January 2024 was reviewed. LVN 5 stated there was no documentation of Hydralazine HCl administration on 1/9/2024 at 8:34 a.m. by LVN 4 on Resident 81's MAR or in Resident 81's progress notes. LVN 5 stated Resident 81 received another dose of Hydralazine HCl on 1/9/24 at 2 p.m. LVN 5 stated that if multiple doses of a blood pressure medication were administered too close together, there was potential for the resident to experience hypotension (low blood pressure) and potential changes in their level of consciousness (a medical term used to describe how awake, alert, and aware someone is). LVN 5 stated nursing staff were to call the doctor and document if they were administering a medication outside of the scheduled administration time. During an interview on 1/10/2024 at 3:35 p.m. with the Director of Nursing (DON), the DON stated medications were required to be administered as ordered by the physician. The DON stated staff have one hour before and one hour after the scheduled administration time to administer the medication. The DON stated if a medication is administered outside of the permitted timeframe, the physician needs to be contacted to ensure that it is safe to proceed with the next scheduled dose. The DON also stated the administration should be documented on the progress note. 2. During a review of Resident 74's admission Record, the admission record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). During a review of Resident 74's H&P, dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's current Physician Orders, the orders indicated staff were to administer a total of nine (9) medications and one supplement at 9 a.m. on 1/9/2024. During an interview on 1/9/2024 at 8:59 a.m., with LVN 4, LVN 4 stated she was preparing to administer medications for Resident 74. During a concurrent observation and interview on 1/9/2024 at 9:02 a.m., inside Resident 74's room, LVN 4 checked Resident 74's blood sugar. LVN 4 stated Resident 74's blood sugar was 110. No medications or supplements were administered. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., outside of Resident 74's room, LVN 4 stated a total of two (2) medications were being administered to Resident 74 and restated that Resident 74's blood sugar was 110. LVN 4 did not prepare any supplements for administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 41 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN 4 then entered Resident 74's room and Resident 74 took one medication with water while LVN 4 administered Lantus into Resident 74's left lower abdomen by injection. LVN 4 did not offer or administer any further medications or supplements to Resident 74. During a review of Resident 74's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated LVN 4 documented she administered nine (9) medications and one supplement scheduled for the 9 a.m. administration. There were seven (7) medications and one supplement documented as administered by LVN 4 that were not observed as administered. The MAR further indicated the Lantus was not supposed to be administered if Resident 74's blood sugar was less than 120, and further indicated LVN 4 documented a blood sugar of 110 and administered the Lantus. During a concurrent interview and record review, on 1/09/2024 at 9:33 a.m., with LVN 4, Resident 74's MAR and physician orders were reviewed. LVN 4 stated the physician order was to not administer the Lantus injection if Resident 74's blood sugar was less than 120. LVN 4 stated she misread the physician order. LVN 4 stated the blood glucose was 110 and the Lantus was administered. LVN 4 stated administration of Lantus put Resident 74 at risk for hypoglycemia and could cause harm to the resident. During a review of Resident 74's care plan dated 1/9/2024, the care plan indicated Resident 74 was at risk for an adverse reaction or change in condition due to the incorrect Lantus administration. 3. During a review of Resident 7's admission Record, the record indicated the facility originally admitted Resident 7 on 9/24/2014 and re-admitted Resident 7 on 7/7/2019. Resident 7's admitting diagnoses included spinal stenosis (narrowing of the spinal canal that can put pressure on the spinal cord and the nerves within the spine), right shoulder contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and cognitive communication deficit. During a review of Resident 7's H&P, dated 11/24/2021, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's current Physician Orders, the orders indicated staff were to administer a total of eleven (11) medications and two supplements at 9 a.m. on 1/9/2024. During an interview on 1/9/2024 at 9:14 a.m., with LVN 4, outside of Resident 7's room, LVN 4 stated she was preparing to administer medications for Resident 7. During a concurrent observation and interview on 1/9/2024 at 9:21 a.m., outside of Resident 7's room, LVN 4 stated a total of seven (7) medications were being administered to Resident 7. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 7's room and Resident 7 took six (6) medications with water, and LVN 4 administered one (1) medication to Resident 7's eyes. LVN 4 did not offer or administer any further medications or supplements to Resident 7. During a review of Resident 7's MAR, for the month of January 2024, the MAR indicated a total of eleven (11) medications and two supplements were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered eleven (11) medications and two supplements scheduled for 9 a.m. administration. There were four (4) medications and two supplements documented on the MAR as administered by LVN 4 that were not observed as administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 42 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 1/11/2024 at 3:54 p.m., with the DON, LVN 4's employee file was reviewed. The DON stated the facility policy was to ensure that a competency assessment was completed for licensed nurses upon hire, stating the facility practice was to have an experienced licensed nurse follow and observe the new licensed nursing staff to assess competency. The DON stated a competency assessment was not completed for LVN 4, and stated there was no documentation in her employee file to indicate an assessment had been done. The DON stated it was not safe for LVN 4 to administer medication to facility residents without the required competencies, and stated it was not correct nursing practice for LVN 4 to document medications or supplements as administered if they were not administered. During a review of the facility's undated, policy and procedure (P&P) titled, Competency Assessment, the P&P indicated Employees will be assessed for competency upon hire and annually. During a review of the facility document, titled Job Description, Job Title: Licensed Vocational Nurse (LVN), dated 8/2011, the document indicated essential duties and responsibilities included: a. Preparing and passing medication as indicated and administering medications according to policy and procedure. b. Contacting the attending physician for required orders as needed. c. Ensuring medications are documented in a timely fashion and in accordance with company policies and procedures. d. Assuring that documentation is accurate. During a review of the facility P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated: a. Medications are administered in accordance with written orders of the attending physician. b. Medications are administered within 60 minutes of the scheduled time (1 hour before and 1 hour after). c. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. d. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 43 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for medication administration for six out of 10 sampled residents (Resident 28, 35, 51, 68, 81, 82) when: 1. Licensed Vocational Nurse (LVN) 4 did not administer the routine 9:00 a.m. dose of medication to Resident 28, 35, 68, 81, and 82 on [DATE]. 2. Resident 28, 35, and 81 was administered Tenormin, Diltiazem, Amlodipine, Labetalol, and Hydralazine (medications used to treat high blood pressure) despite meeting the hold parameters (when a medication is not administered based on a specific condition) for having a heart rate lower than 60. 3. Resident 51 was administered Midodrine (medication used to treat low blood pressure) despite meeting the hold parameters for having a systolic blood pressure (SBP, the maximum blood pressure during contraction of the ventricles [the two lower chambers of the heart responsible for pumping blood out of the heart]) more than 110. These deficient practices caused Resident's 28, 35, 68, 81, and 82 to have an interruption with their medication therapy, and exposed Resident's 28, 35, 51, and 81 to a potential adverse effect to their medications. Findings: 1. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles) and kidney failure (occurs when kidneys become unable to filter waste products from the blood, kidneys lose their filtering ability). During a review of Resident 28's History and Physical (H&P) dated [DATE], the H&P indicated Resident 28 did not have the capacity to understand and make decisions. The H&P indicated Resident 28 had a diagnosis of Non-ST-elevation myocardial infarction ([NSTEMI] is a type of heart attack that usually happens when your heart's need for oxygen can't be met). During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 28's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 28 required substantial/maximal assistance from staff for all activities of daily living (ADLs, activities performed daily such as personal hygiene, grooming, dressing, and toileting). During a review of Resident 28's Order Summary Report, the order summary report indicated Resident 28 was to receive: 1. Aspirin 81 milligrams (mg, unit of measurement), by mouth, one time a day, for cerebral vascular disease ([CVA] an interruption in the flow of blood to cells in the brain, when cells in the brain are deprived of oxygen, they die) prophylaxis (to prevent). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 44 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 2. Colace 100 mg, by mouth, one time a day, for stool softener. Level of Harm - Minimal harm or potential for actual harm 3. Hydroxychloroquine sulfate 200 mg, by mouth, 2 times a day, for rheumatoid arthritis (body's immune system attacks its own tissue, affects joint linings, causing painful swelling). Residents Affected - Some 4. Lasix tablet 20 mg, 1 tablet a day, by mouth, for congestive heart failure (CHF, chronic condition in which the heart doesn't pump blood as well as it should). 5. Tenormin 50 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold medication if SBP was less than 110, and to hold if heart rate was less than 60. 6. Uloric 80 mg, by mouth, one time a day, for gout (form of arthritis characterized by severe pain, redness, and tenderness in joints). 7. Cranberry 2 capsules 425 mg, by mouth, two times a day, for urinary tract infection (UTI, infection of the bladder) prophylaxis. 8. Potassium chloride 10 Milliequivalent per liter (MEQ) by mouth, one time a day, for supplement. 9. [NAME]-vita tablet, by mouth, one time a day, for renal (kidney) supplement. During a review of Resident 28's Medication Administration Record (MAR), for the month of [DATE], the MAR indicated on [DATE], Resident 28 received Tenormin however the resident's heart rate was 58. During a review of Resident 28's MAR, for the month of [DATE], the MAR indicated on [DATE], Resident 28 did not receive his 9:00 a.m. dose of Aspirin 81 mg, Colace 100 mg, Lasix 20 mg, potassium chloride 10 MEQ, Rena Vite tablet, Tenormin 50 mg, uloric 80 mg, cranberry capsule 425 mg and hydroxychloroquine sulfate 200 mg. 2. During a review of Resident 35's admission Record, the admission record indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included of heart failure and peripheral vascular disease ([PVD] a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 35's H&P dated [DATE], the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills daily decision making was severely impaired. The MDS indicated Resident 35 was dependent on staff for all ADLs. The MDS indicated Resident 35's speech was unclear. The MDs indicated Resident 35 had a diagnosis of PVD. During a review of Resident 35's Order Summary Report, the order summary report indicated Resident 35 was to receive: 1. Aspirin 81 oral tablet chewable, give 1 tablet, via G-tube, one time a day, for CVA prophylaxis. 2. Cholecalciferol 25 micrograms (mcg, unit of measurement), give via gastrostomy tube (G-tube, tube surgically inserted into the stomach for nutrition, hydration, and medications), in the morning, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 45 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 for supplement. Level of Harm - Minimal harm or potential for actual harm 3. Colace 100 mg, via G-tube, for stool softener. 4. Cranberry tablet 450 mg, give 1 tablet, via G-tube, for UTI prophylaxis. Residents Affected - Some 5. Cyanocobalamin tablet 10000 mcg, 1 time a day, for supplement. 6. Multivitamins with mineral, 1 tablet, via G-tube, one time a day, for supplement. 7. Vitamin C tablet 500 mg, give 1 tablet, via G-tube, one time a day, for supplement. 8. Apixaban tablet 2.5 mg, give one tablet, via G-tube, two times a day, for PVD. 9. Diltiazem 30 mg, one tablet, via G-tube, every 8 hours, for high blood pressure, hold if SBP was less than 105 and hold if heart rate was less than 65. During a review of Resident 35's MAR, for the month of [DATE], the MAR indicated on [DATE], Resident 35 did not receive his 9:00 a.m. dose of Aspirin 81 mg, Colace 100 mg, cholecalciferol 25 mcg, cranberry 450 mg, cyanocobalamin 1000 mcg, multivitamin, vitamin C 500 mg, and Apixaban 2.5 mg. During a review of Resident 35's MAR, for the month of [DATE], the MAR indicated Resident 35's heart rate was the following on the following dates and times: On [DATE] at 2 p.m., Resident 35's heart rate was 62. On [DATE] at 2 p.m., Resident 35's heart rate was 63. On [DATE] at 10 p.m., Resident 35's heart rate was 60. On [DATE] at 10 p.m., Resident 35's heart rate was 63. According to the MAR, Resident 35's heart rate met the hold parameters however Diltiazem was given. 3. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid) and pulmonary hypertension (a condition that affects the blood vessels in the lungs which develops when the blood pressure in your lungs is higher than normal). During a review of Resident 51's H&P dated [DATE], H&P indicated Resident 51 had the capacity to understand and make decisions. The H&P indicated Resident 51 had a diagnosis of rheumatoid arthritis (body's immune system attacks its own tissue, affects joint linings, causing painful swelling). During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 51 required substantial assistance with personal hygiene and toileting hygiene and required set up assistance for eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 46 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The MDS indicated Resident 51 had a diagnosis of coronary artery disease (CAD, artery disease that is caused by plaque buildup in the wall of the arteries that supply blood to the heart, causes coronary arteries to narrow, limiting blood flow to the heart). During a review of Resident 51's Order Summary report, dated [DATE], the Order Summary Report indicated to administer Midodrine 10 mg, give 1 tablet, by mouth, two times a day for low blood pressure, hold if SBP more than 110. During a review of Resident 51's MAR, for the month of [DATE], the MAR indicated the following: On [DATE] at 5:00 p.m., Resident 51's SBP was 137. On [DATE] at 9:00 a.m., Resident 51's SBP was 116. On [DATE] at 9:00 a.m., Resident 51's SBP was 115. The MAR indicated Resident 51's SBP met the hold parameters however Midodrine was administered. During a concurrent interview and record review on [DATE] at 2:21 p.m. with the MDS Nurse (MDSN), Resident 51's MAR, for the month of [DATE] was reviewed. The MAR indicated on [DATE], for the 9:00 a.m. administration time, Resident 51's SBP was 116. Resident 51's SBP met the hold parameters however Midodrine was administered. The MDSN stated she should not have administered Midodrine medication to Resident 51 because the resident's SBP was higher than 110. The MDSN stated she did not know why she gave the medication to Resident 51. The MDSN stated it was important to follow the medication parameters to prevent a negative outcome for residents. 4. During a review of Resident 68's admission Record, the admission record indicated Resident 68 was originally admitted to the facility on [DATE] with diagnoses that included cardiomyopathy (acquired or hereditary disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body and can lead to heart failure) and atherosclerosis of aorta (a material called plaque [fat and calcium] built up in the inside wall of a large blood vessel [aorta]). During a review of Resident 68's H&P dated [DATE], the H&P indicated Resident 68 did not have the capacity to understand and make decisions. The H&P indicated Resident 68 had a diagnosis of hypertension (high blood pressure). During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 68 required substantial assistance for all ADLS. The MDS indicated Resident 68 had a diagnosis of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 68's Order Summary Report, the order summary report indicated Resident 68 was to receive: 1. Aspirin 81 mg, give 1 tablet by mouth, one time a day. 2. Benazepril tablet 20 mg, give 1 tablet by mouth, one time a day, for high blood pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 47 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 3. Colace 100 mg, by mouth, one time a day. Level of Harm - Minimal harm or potential for actual harm 4. Lactulose solution 20 gram (gm, unit of measurement) per (/) 30 milliliters (ml, unit of measurement), by mouth, one time a day, for elevated ammonia level (waste product normally processed in the liver and removed through the urine). Residents Affected - Some 5. Multivitamin with mineral 1 tablet, by mouth, one time a day, for supplement. 6. Vitamin B12 oral tablet 500 mcg, give 1 tablet by mouth, one time a day, for supplement. 7. Vitamin D3 25 mcg, give 2 tablets by mouth, one time a day, for low vitamin D level. 8. Carvedilol 12.5 mg, give 1 tablet by mouth, 2 times a day, for high blood pressure. 9. Cranberry tablet 450 mg, give 2 tablets by mouth, two times a day. 10. Namenda 10 mg tablet, give 1 tablet by mouth, two times a day, for dementia. During a review of Resident 68's MAR, for the month of [DATE], the MAR indicated on [DATE] Resident 68 did not receive his 9:00 a.m. dose of Aspirin 81 mg, Benazepril 20 mg, Colace 100 mg, lactulose solution 20 gm/ml, multivitamin with mineral, Vitamin B12 500 mcg, Vitamin D3 25 mcg, Carvedilol 12.5 mg, cranberry 10 mg, and Namenda 10 mg. 5. During a review of Resident 81's admission Record, the admission record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) and end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognitive skills for daily decision making was intact. The MDS indicated Resident 81 required assistance with setup or cleanup for eating, and supervision or touching assistance for oral hygiene, toileting hygiene and personal hygiene. The MDS indicated Resident 81 had a diagnosis of diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 81's H&P dated [DATE], H&P indicated Resident 81 was not able to make his own decisions however was able to make needs known. The H&P indicated Resident 81 had a history of benign prostatic hyperplasia (BPH, a condition in men in which the prostate gland is enlarged). During a review of Resident 81's Order Summary Report, the order summary report indicated Resident 81 was to receive: 1. Amlodipine besylate tablet 10 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold if SBP is less than 110 and heart rate is less than 60. 2. Hydralazine tablet 25 mg, give 1 tablet, by mouth, every 8 hours, for high blood pressure, hold (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 48 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 medication if SBP less than 110 and if heart rate less 60. Level of Harm - Minimal harm or potential for actual harm 3. Labetalol tablet 200 mg, give 1 tablet by mouth, every 12 hours, for high blood pressure, hold if SBP less than 110 and heart rate less than 60. Residents Affected - Some During a review of Resident 81's MAR, for the month of [DATE], the MAR indicated the following: On [DATE] at 2:00 p.m., Resident 81's heart rate was 57, however Amlodipine administered. On [DATE] at 9:00 a.m., Resident 81's heart rate was 57, however Labetalol was administered. On [DATE] at 2:00 p.m., Resident 81's heart rate was 57, however Hydralazine was administered. 6. During a review of Resident 82's admission Record, the admission record indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis that included heart failure (progressive heart disease that affects pumping action of the heart muscles) and nonrheumatic aortic valve stenosis (a thickening and narrowing of the valve between the heart's main pumping chamber and the aorta, creates a smaller opening for blood to pass through and reduces or blocks blood flow from the heart to the rest of the body). During a review of Resident 82's H&P dated [DATE], the H&P indicated Resident 82 was able to give appropriate consent based on adequate decision-making capacity. The H&P indicated Resident 82 had a history of kidney transplant (a surgery to placing a healthy kidney from a living or deceased donor into a person whose kidneys no longer function). During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82's cognitive skills for daily decision making was intact. The MDS indicated Resident 82 required supervision for all ADLs. The MDS indicated Resident 82 had a diagnosis of diabetes mellitus. During a review of Resident 82's Order Summary Report, the order summary report indicated Resident 82 was to receive: 1. Cinacalcet oral tablet 30 mg, give 1 tablet, by mouth, in the morning for chronic kidney disease (CKD, gradual loss of kidney function. Kidneys are unable to filter wastes and excess fluids from blood). 2. Furosemide oral tablet 40 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold if SBP less than 110 and if heart rate less than 60. 3. Lisinopril oral tablet 10 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold if SBP less than 110 and if heart rate less than 60. 4. Prednisone oral tablet 5 mg, give 1 tablet, by mouth, one time a day, for renal transplant. 5. Valacyclovir oral tablet 50 mg, give 1000 mg by mouth, one time a day, for warts. 6. Colace give 100 mg, by mouth, two times a day. 7. Prograf oral capsule 0.5 mg, give 1 capsule, by mouth, every 12 hours, for renal transplant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 49 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0755 Level of Harm - Minimal harm or potential for actual harm 8. Ketorolac tromethamine ophthalmic solution 4%, instill 1 drop in left eye, four times a day, for status post (S/P) cataract (a clouding of the lens of the eye) surgery. 9. Ofloxacin ophthalmic solution 0.3 %, instill 1 drop in left eye, four times a day, for status post (S/P) cataract surgery. Residents Affected - Some 10. Prednisolone acetate ophthalmic suspension 1 %, instill 1 drop in left eye, four times a day, for S/P cataract surgery. During a review of Resident 82's MAR, for the month of [DATE], the MAR indicated the following: On [DATE] at 9:00 a.m., Resident 82's SBP was 104. The MAR indicated Resident 82's SBP met the hold parameters however Furosemide and Lisinopril were administered. The MAR indicated on [DATE], Resident 82 did not receive his 9:00 a.m. dose of Cinacalcet 30 mg, Colace 100 mg, Furosemide 40 mg, Lisinopril 10 mg, Ketorolac tromethamine 4%, Ofloxacin 0.3 %, Prednisone 5 mg, Prednisolone acetate 1 %, Prograf oral capsule 0.5 mg, and Valacyclovir 50 mg. During an interview on [DATE] at 8:25 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated on [DATE] she took over LVN 4's assignment when LVN 4 went home for the day. LVN 5 stated LVN 4 did not give her report before leaving. LVN 5 stated she did not remember what time she took over LVN 4's assignment but administered the resident's lunch time medications. LVN 5 stated LVN 4 did not inform LVN 5 the resident's 9:00 a.m. meds were not administered. LVN 5 stated medications that have hold parameters must be held if the resident met the parameters. LVN 5 stated if medication was administered it could cause a resident to have a negative response to medication. During an interview on [DATE] at 3:45 p.m. with the Director of Nursing (DON), the DON stated she expected the licensed nurses to pass all resident medications at their assigned times. The DON stated if the MAR was blank, it meant the medication was not given. The DON stated that if a medication was not given, the nurse must document the reason why it was not given. The DON stated it was not acceptable to leave the MAR blank. The DON stated if a resident's heart rate or blood pressure met the hold parameters the medication should not be administered to the resident. The DON stated that if the medication was administered to the resident, it could cause the resident harm instead of helping them. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 10/2017, the P&P indicated the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administrating the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. The P&P indicated medications are administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 50 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure their medication error rate was less than five (5) percent (%) when Licensed Vocational Nurse (LVN) 4 failed to competently administer medications to three (3) of five (5) randomly selected residents (Residents 81, 74, and 7) during the medication administration observation. Residents Affected - Some The outcome was 16 medication errors out of thirty opportunities for errors, which resulted in a Medication Administration Error Rate of fifty-three (53) percent, based on the following: 1. Resident 81 did not receive four (4) ordered medications that were documented as administered, and Resident 81 received one (1) medication more than one hour after the permitted administration time. 2. Resident 74 did not receive seven (7) ordered medications that were documented as administered, and Resident 74 received one (1) medication outside of the ordered holding parameters (specific instructions for when and when not to administer a medication based on measurable values). 3. Resident 7 did not receive four (4) ordered medications that were documented as administered. These deficient practices created the potential for residents to experience harm from pain related to non-administered pain medication, low blood pressure related to blood pressure medication being administered outside of the schedule time and too close to the next scheduled dose, and low blood sugar related to insulin administered outside of the ordered parameters. The deficient practice also created the potential for interruptions in health maintenance and improvement related to missed administrations of necessary medications. Cross Reference: F-tag 726, F-tag 760, and F-tag 684 Findings: 1. During a review of Resident 81's admission Record, the admission record indicated the facility originally admitted Resident 81 on 7/29/2022 and re-admitted Resident 81 on 12/15/2023. Resident 81's admitting diagnoses included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (a treatment for people whose kidneys are failing), type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood, creating risk of heart attack and stroke). During a review of Resident 81's History and Physical (H&P), dated 12/15/2023, the H&P indicated Resident 81 did not have the capacity to make his own decisions. During a review of Resident 81's Physician Orders, dated 12/15/2023, the orders indicated staff were supposed to administer medications a total of seven (7) medications at 9 a.m. on 1/9/2024. The medications were as follows: 1. Aspirin 81 milligram (mg, a unit of dose measurement) tablet, by mouth, once a day, for stroke prevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 51 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0759 2. Polyethylene glycol 3350, one packet, by mouth, one time a day, for bowel (intestine) management. Level of Harm - Minimal harm or potential for actual harm 3. Nephro-vite tablet, once a day, for supplement. 4. Docusate sodium 100 mg, by mouth, once a day, for stool softener. Residents Affected - Some 5. Labetalol 200 mg, by mouth, every 12 hours, for high blood pressure. 6. Amlodipine besylate 10 mg, by mouth, once a day, for high blood pressure. 7. Insulin glargine 15 units subcutaneously (under the skin), every 12 hours, for DM. During an interview on 1/9/2024 at 8:20 a.m., with LVN 4, LVN 4 stated she was preparing to administer medications for Resident 81 and had not administered any medications yet. During an observation on 1/9/2024 at 8:24 a.m., inside Resident 81's room, LVN 4 checked Resident 81's heart rate and blood pressure. No medications were administered. During a concurrent observation and interview on 1/9/2024 at 8:34 a.m., outside of Resident 81's room, LVN 4 prepared a total of three (3) medications for Resident 81. After dispensing the medications, LVN 4 confirmed a total of three (3) medications were being administered to Resident 81. LVN 4 then entered Resident 81's room and Resident 81 took all three (3) medications with water. The three medications administered were abetalol HCl, amlodipine besylate, and hydralazine HCl (medication to treat high blood pressure). No further medications were administered. During an observation on 1/9/2024 at 8:36 a.m., at Resident 81's bedside, LVN 4 checked Resident 81's blood sugar then exited the room. No medications were administered. During a concurrent observation and interview on 1/9/2024 at 8:41 a.m., outside of Resident 81's room, with LVN 4, LVN 4 prepared one (1) injection of insulin glargine for Resident 81 and confirmed a total of one (1) medication was to be administered. LVN 4 then entered Resident 81's room and Resident 81 refused the insulin glargine administration. LVN 4 exited the room with the one (1) unadministered medication and returned the medication to the medication cart. No further medications were offered to or administered to Resident 81. During a review of Resident 81's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated a total of seven (7) medications were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered six (6) scheduled 9 a.m. medications, and one (1) refusal of the insulin glargine. The MAR further indicated Resident 81's hydralazine HCl was scheduled for administration at 6 a.m., 2 p.m., and 10 p.m. The hydralazine HCl administered at 8:34 a.m. by LVN 4 was not documented on the MAR. There were four (4) medications documented as administered by LVN 4 on the MAR that were not observed as administered. During a review of document titled, Medication [Administration] Audit Report, dated 1/9/2024, the document indicated Resident 81 had a total of seven (7) medications scheduled for administration at 9 a.m. The document indicated LVN 4 documented she administered a total of seven (7) medications to Resident 81 between 8:22 a.m. and 8:43 a.m. The hydralazine HCl administered at 8:34 a.m. by LVN 4 was not documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 52 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0759 Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 74's admission Record, the record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). Residents Affected - Some During a review of Resident 74's H&P, dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's current physician orders, the orders indicated staff were supposed to administer a total of nine (9) medications at 9 a.m. on 1/9/2024. The medications were as follows: 1. Ferrous sulfate 325 mg tablet, twice a day, for anemia. 2. Cholecalciferol (Vitamin D3) 1000 unit, once a day, for supplement. 3. Multivitamin, once a day, for supplement. 4. Vitamin C 500 mg tablet. 5. [NAME]-Vite (vitamin), one a day, for renal integrity. 6. Eliquis (apixaban) 5 mg, by mouth, once a day, for atrial fibrillation (abnormal heartbeat). 7. Magnesium-oxide 400 mg tablet, twice a day, for supplement. 8. Insulin glargine (Lantus) 10 units subcutaneously, once a day, for DM, with orders to not administer if Resident 74's blood sugar was less than 120. 9. Lidocaine 5% patch, applied above right pelvis and low back, once a day, for pain management. During an interview on 1/9/2024 at 8:59 a.m., with LVN 4, LVN 4 stated she was preparing to administer medications for Resident 74. During a concurrent observation and interview on 1/9/2024 at 9:02 a.m., inside Resident 74's room, LVN 4 checked Resident 74's blood sugar. LVN 4 stated Resident 74's blood sugar was 110. No medications were administered. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., outside of Resident 74's room, LVN 4 prepared a total of two (2) medications for Resident 74. After preparing the medications, LVN 4 confirmed a total of two (2) medications were being administered to Resident 74 (Eliquis and Lantus) and restated that Resident 74's blood sugar was 110. LVN 4 then entered Resident 74's room and Resident 74 took the Eliquis with water while LVN 4 injected 10 units of Lantus into Resident 74's left lower abdomen. No further medications were offered to or administered to Resident 74, and LVN began preparing medications for the next resident at 9:14 a.m. During a review of Resident 74's MAR, for the month of January 2024, the MAR indicated a total of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 53 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0759 Level of Harm - Minimal harm or potential for actual harm nine (9) medications were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered nine (9) scheduled 9 a.m. medications. There were seven (7) medications documented as administered by LVN 4 on the MAR that were not observed as administered. The MAR also indicated LVN 4 documented a blood sugar of 110 and documented that the Lantus had been administered despite the order to not administer the medication if the blood sugar was less than 120. Residents Affected - Some During a review of a document titled, Medication [Administration] Audit Report, dated 1/9/2024, the document indicated Resident 74 had a total of nine (9) medications scheduled for administration at 9 a.m. The document indicated LVN 4 documented she administered a total of nine (9) medications to Resident 74 between 8:58 a.m. and 9:12 a.m. During a concurrent interview and record review, on 1/09/2024 at 9:33 a.m., with LVN 4, Resident 74's MAR and physician orders were reviewed. LVN 4 stated the physician order was to not administer the Lantus injection if Resident 74's blood sugar was less than 120. LVN 4 stated she misread the physician order. LVN 4 stated the blood glucose was 110 and the Lantus was administered. LVN 4 stated administration of Lantus put Resident 74 at risk for hypoglycemia and could cause harm to the resident. 3. During a review of Resident 7's admission Record, the record indicated the facility originally admitted Resident 7 on 9/24/2014 and re-admitted Resident 7 on 7/7/2019. Resident 7's admitting diagnoses included spinal stenosis (narrowing of the spinal canal that can put pressure on the spinal cord and the nerves within the spine), right shoulder contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and cognitive communication deficit. During a review of Resident 7's H&P, dated 11/24/2021, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's current physician orders, the orders indicated staff were to administer a total of eleven (11) medications at 9 a.m. on 1/9/2024. The medications were as follows: 1. Multivitamin with minerals, one tablet, once a day, for supplement. 2. Lidocaine-Prilocaine external cream 2.5%, applied to right shoulder, twice a day, for pain management. 3. Cholecalciferol (Vitamin D3) two 1000-unit tablets, once a day, for low vitamin D levels. 4. Potassium chloride 50 milliequivalents (mEq, a unit of dose measurement), in the morning, for supplement secondary to furosemide (medication that makes you urinate) use. 5. Docusate sodium 100 mg, in the morning, for stool softener. 6. Furosemide 40 mg tablet, in the morning, for extremity edema (swelling). 7. Sodium chloride solution 5% instillation of one drop to the right eye, twice a day, for corneal edema (swelling of the outermost layer of the eye). 8. Gabapentin 100 mg capsule, twice a day, for pain management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 54 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0759 9. Artificial tears instillation of one drop to both eyes, four times, a day for dry eyes. Level of Harm - Minimal harm or potential for actual harm 10. Divalproex sodium 500 mg, twice a day, for seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements) disorder. Residents Affected - Some 11. Levetiracetam 750 mg, twice a day, for seizure disorder. During an interview on 1/9/2024 at 9:14 a.m., with LVN 4, outside of Resident 7's room, LVN 4 stated she was preparing to administer medications for Resident 7. During a concurrent observation and interview on 1/9/2024 at 9:21 a.m., outside of Resident 7's room, LVN 4 prepared a total of six (6) medications for Resident 7. After preparing the medications, LVN 4 confirmed a total of 6 (6) medications were being administered to Resident 7. LVN 4 then entered Resident 7's room and Resident 7 took 5 medications with water, and LVN 4 administered one (1) medication (artificial tears) to both of Resident 7's eyes. No further medications were offered to or administered to Resident 7. During a review of Resident 7's MAR, for the month of January 2024, the MAR indicated a total of eleven (11) medications were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered eleven (11) scheduled 9 a.m. medications. There were four (4) medications documented as administered by LVN 4 on the MAR that were not observed as administered. During a review of a document titled, Medication [Administration] Audit Report, dated 1/9/2024, the document indicated Resident 7 had a total of eleven (11) medications scheduled for administration at 9 a.m. The document indicated LVN 4 documented she administered a total of eleven (11) medications to Resident 7 between 9:15 a.m. and 9:20 a.m. During an interview on 1/11/2024 at 3:35 p.m., with the Director of Nursing (DON), the DON stated medications are to be administered as ordered by the physician. The DON stated staff have one hour before and one hour after the scheduled administration time to administer medications. The DON stated medication administered outside of the scheduled time required prior physician notification to ensure it was safe, and stated there should be documentation in the resident's medical record to indicate when the medication was administered. The DON also stated documentation of medication administration is supposed to be done immediately at time of administration and should be accurate. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, indicated: a. Medications are administered in accordance with written orders of the attending physician. b. Medications are administered within 60 minutes of the scheduled time (1 hour before and 1 hour after). c. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. d. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 55 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0760 Ensure that residents are free from significant medication errors. 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 ensure one of five sampled residents (Resident 74) was free of significant medication errors by failing to: Residents Affected - Few 1. Ensure Licensed Vocational Nurse (LVN) 4 did not administer 10 units (a unit of measurement for insulin) of Lantus (insulin glargine, a medication used to control blood sugar levels) when resident 74's blood sugar was outside of the holding parameters (specific instructions for when and when not to administer a medication based on measurable values). 2. Ensure Licensed staff did not document administration of thirty-seven (37) of Lidocaine 5% patches (medicated patch applied to the skin for pain management) for Resident 74, when only fourteen (14) patches had been dispensed to the facility. These deficient practices had the potential to result in avoidable harm from pain related to non-administered pain medication, and low blood sugar related to insulin being administered outside of the ordered parameters. Cross Reference: F-tag 726, F-tag 759, and F-tag 684 Findings: During a review of Resident 74's admission Record, the admission record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). During a review of Resident 74's History and Physical (H&P), dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's active Physician Orders, the orders indicated staff were to administer 10 units of Lantus subcutaneously (injected beneath the skin) once a day for DM, with orders to not administer the medication if Resident 74's blood sugar was less than 120. The orders also indicated staff were to apply a Lidocaine 5% patch to Resident 74's right lower back, once a day, for pain management, starting on 11/25/2023. During a concurrent observation and interview on 1/9/2024 at 9:02 a.m., inside Resident 74's room, LVN 4 checked Resident 74's blood sugar. LVN 4 stated Resident 74's blood sugar was 110. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., outside of Resident 74's room, LVN 4 prepared Resident 74's Lantus injection for administration and restated that Resident 74's blood sugar was 110. LVN 4 then entered Resident 74's room and injected the 10 units of Lantus into Resident 74's left lower abdomen. LVN 4 did not apply a Lidocaine 5% patch to Resident 74's right lower back. During a concurrent interview and record review, on 1/09/2024 at 9:33 a.m., with LVN 4, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 56 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0760 Level of Harm - Minimal harm or potential for actual harm 74's Medication Administration Record (MAR) and physician orders were reviewed. LVN 4 stated the physician order was to not administer the Lantus injection if Resident 74's blood sugar was less than 120. LVN 4 stated she misread the physician order. LVN 4 stated Resident 74's blood sugar level was 110 and the Lantus was administered. LVN 4 stated the administration of Lantus put Resident 74 at risk for hypoglycemia and could cause harm to the resident. Residents Affected - Few During a review of Resident 74's MAR, for the month of November 2023, the MAR indicated licensed facility staff documented Resident 74's Lidocaine 5% patch as administered on 11/25/2023, 11/26/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/20/2023. The MAR indicated a total of six administrations of Resident 74's Lidocaine 5% patch for the month of 11/2023. During a review of Resident 74's MAR, for the month of December 2023, the MAR indicated licensed facility staff documented Resident 74's Lidocaine 5% patch as administered on: 12/1/2023, 12/2/2023, 12/3/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/7/2023, 12/8/2023, 12/9/2023, 12/10/2023, 12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/17/2023, 12/20/2023, 12/21/2023, 12/22/2023, 12/23/2023, 12/24/2023, 12/26/2023, 12/27/2023, 12/28/2023, and 12/31/2023. The MAR indicated a total of 24 administrations of Resident 74's Lidocaine 5% patch for the month of 12/2023. During a review of Resident 74's MAR, for the month of January 2024, the MAR indicated LVN 4 documented Resident 74's Lidocaine 5% patch as administered on 1/9/2024. Further review of the MAR indicated other licensed facility staff documented the Lidocaine 5% patch as administered on: 1/1/2024, 1/2/2024, 1/3/2024, 1/4/2024, 1/5/2024, and 1/7/2024. The MAR indicated a total of 7 administrations of Resident 74's Lidocaine 5% patch for the month of 1/2024. During a concurrent observation and interview, on 1/9/2024 at 1 p.m., at Resident 74's bedside, Resident 74 rolled into a left-facing position in her bed. No Lidocaine 5% patch was observed on Resident 74's right lower back or displaced in Resident 74's bed linens. Resident 74 stated she did not receive the Lidocaine 5% patch that day and stated the patch had not been offered to her. During a concurrent observation and interview on 1/9/2024 at 1:08 p.m., with LVN 5, LVN 5 opened the medication cart and removed the current inventory of Resident 74's Lidocaine 5% patches. LVN 5 stated the label affixed to the bag containing Resident 74's inventory of Lidocaine 5% patches was dated 11/24/2023 and indicated a total of 14 patches had been dispensed. LVN 5 stated there were two patches remaining in Resident 74's inventory. LVN 5 stated no additional patches had been requested or dispensed from the pharmacy. During an interview on 1/9/2024 at 1:44 p.m., with the facility's contracted pharmacy, the pharmacy staff stated a total of 14 Lidocaine 5% patches had been dispensed to the facility on [DATE] for Resident 74. Pharmacy staff stated no refills had been requested or delivered. The pharmacy staff stated that when a medication is dispensed to the facility, the staff receiving the medication sign a receipt to confirm the medication was received. During a review of a document titled, Manifest: [Facility Name], dated 11/25/2023, the document indicated LVN 6 signed the document on 11/25/2023 at 4:14 a.m., confirming receipt of 14 Lidocaine 5% patches for Resident 74. During a concurrent record review and interview on 1/11/2024 at 3:35 p.m., with the Director of Nursing (DON), Resident 74's physician orders, MARs for November 2023, December 2023, January 2024, and the Lidocaine 5% patch delivery records from the contracted pharmacy were reviewed. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 57 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications were supposed to be administered as ordered by the physician. The DON stated that not following physician orders for Lantus administration could cause an alteration in Resident 74's blood sugar, and a potentially harmful change in condition. The DON further stated only 14 Lidocaine 5% patches had been delivered to the facility, and stated there were not enough patches delivered to account for the 37 administrations documented from 11/25/2023 to 1/9/2024. The DON stated the medications had not been administered as ordered and stated that a resident's pain could go unaddressed if they did not receive their pain medication as ordered. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, indicated: a. Medications are administered in accordance with written orders of the attending physician. b. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 58 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain the results for one of two sampled residents (Resident 74) computed tomography (CT, imaging that helps detect internal injuries and diseases) scan in a timely manner when Resident 74 was readmitted to the facility from the general acute care hospital (GACH). Residents Affected - Few This failure resulted in Resident 74's physician being notified two weeks after the CT scan was completed with results that indicated a compression fracture (type of broken bone that can cause the vertebra [bone in the spine] to collapse) of the second lumbar vertebrae (L2, bone in the lower end of the spinal column). Findings: During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's History and Physical (H&P), dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, a comprehensive resident assessment and care screening tool,) dated 12/14/2023, the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 74's cognition was intact (ability to think and reason). The MDS indicated Resident 74 required moderate assistance with bed mobility, maximal assistance with toileting, bathing, and dressing, and required setup or clean-up assistance with personal hygiene. The MDS indicated Resident 74 had a fall with a major injury. During a review of Resident 74's Change of Condition (COC), dated 11/6/2023, the COC indicated on 11/6/2023, Resident 74 returned to her room from the shower room and was being assisted to bed by the certified nursing assistant (CNA). The COC indicated Resident 74 stood up to transfer to the bed, was unable to reach for the bed handles, and fell and landed on her back. The COC indicated Physician 2 was informed and gave orders for an X-ray (imaging that creases pictures of the inside of the body) of the hip, spine, head, leg, and pelvis. The COC indicated Resident 74 complained of lower back and left hip pain. During a review of Resident 74's Radiology Results Report, dated 11/6/2023, the Radiology Results Report indicated the lumbar spine X-ray indicated a result of a compression deformity at the L2 level, age indeterminate (not exactly known). During a review of Resident 74's Progress Notes, dated 11/6/2023 and timed at 1:48 p.m., the Progress Note indicated Physician 2 was informed of Resident 74's X-ray results and Physician 2 ordered a CT scan of the head and lumbar. During a review of Resident 74's COC, dated 11/28/2023, the COC indicated Resident 74 complained of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 59 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lower back pain and another lumbar X-ray was done which indicated a result of a compression deformity at the L2 level, age determinate. The COC indicated Physician 2 was notified that Resident 74 had not received the CT scan of the head and lumbar due to insurance. The COC indicated Physician 2 ordered for Resident 74's transfer to the GACH for CT scan of the head and lumbar. During a review of Resident 74's GACH Radiology Report, dated 11/28/2023, the Radiology Report indicated the report was faxed to the facility on [DATE]. The Radiology Report indicated the lumbar CT scan result indicated an acute compression fracture of L2. During a review of Resident 74's admission Assessment, dated 11/28/2023, the admission Assessment indicated Resident 74 was transferred to the GACH for a CT scan of the head and lumbar and was readmitted to the facility. The admission Assessment had no indication of the report provided to the admitting nurse and of the results of the CT scan. During a review of Resident 74's COC, dated 12/12/2023, the COC indicated the lumbar CT scan results were received from the GACH and Physician 2 was notified of the results. The COC indicated Physician 2 ordered for Resident 74 to see a neurosurgeon in one to six weeks for evaluation. During an interview on 1/10/2024 at 8:59 a.m., with Registered Nurse (RN) 2, RN 2 stated Resident 74 was transferred to the GACH on her shift and was readmitted to the facility the following shift. RN 2 stated she and the other nurses were unaware of Resident 74's compression fracture until the facility received the results from the GACH two weeks later. RN 2 stated when Resident 74 was brought back to the facility, the GACH did not send any paperwork with the resident regarding the CT scan results. RN 2 stated the facility's medical personnel followed up with the GACH in obtaining the CT scan results. During an interview on 1/10/2024 at 11:55 a.m., with the Medical Record Director (MRD), the MRD stated he requested Resident 74's CT scan results on 12/4/2023 but did not receive them until 12/12/2023. During an interview on 1/10/2024 at 1:10 p.m., with Physician 3, Physician 3 stated she expected to be notified of abnormal results of any kind promptly to develop a plan of care based on those results. During an interview on 1/10/2024 at 3:46 p.m., with RN 3, RN 3 stated Resident 74 was transferred to the hospital on [DATE] for a CT scan and was readmitted to the facility that same night. RN 3 stated normally when a resident was readmitted to the facility from the hospital, she would receive report prior to the residents' arrival. RN 3 stated she had not received report and Resident 74 was brought back to the facility. RN 3 stated she was curious what the CT scan results were, but she did not follow up with the GACH. RN 3 stated she could have called the GACH and spoken to the physician. RN 3 stated she should have obtained the CT scan results and informed the physician so Resident 74 could receive the proper care. During an interview on 1/11/2024 at 10:36 a.m., with the Director of Nursing (DON), the DON stated the admitting nurse should have received the results of the CT scan, however, all the nurses had the responsibility to follow-up on diagnostic tests for the residents. The DON stated obtaining the results and notifying the physician was important to provide the appropriate care for the resident. During a review of the facility's Registered Nurse (RN) Job Description, dated 1/27/2022, the Job (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 60 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Description indicated, Essential duties and responsibilities include . Makes actual patient rounds, assessing and observing the following at least three times per day: Monitoring lab and x-ray values related to patient's condition. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 1/24/2017, the P&P indicated, A change of condition is a sudden or marked different in resident's . lab or x-ray results . All changes of condition in a resident shall be handled promptly. Event ID: Facility ID: 055170 If continuation sheet Page 61 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the kitchen staff failed to wash their hands prior to becoming in contact with food, failed to check food temperatures, and failed to store food under sanitary conditions when the following occurred: 1. The Dietary Supervisor (DS) did not wash their hands before checking food temperatures. 2. The refrigerator stored food without a use by date. 3. The refrigerator stored food that was spoiled. 4. The freezer stored food without the date that it was placed in the freezer and did not have a use by date. 5. Food temperatures were not checked prior to serving food to residents. These deficient practices had the potential to result in the transmission of infectious agents that could lead to food borne illnesses in vulnerable residents. Findings: During a concurrent initial kitchen tour observation and interview on 1/8/2024 at 8:55 a.m. with [NAME] 1, in the dry storage room, [NAME] 1 stated items placed in the storage room were dated with the received date (date item was placed on the shelf), the date the item was opened, and a use by date (date item must be removed or the expiration date). During an observation on 1/8/2024 at 9:05 a.m. in the dry storage room, there was an open container of browning and seasoning sauce with no use by date. Observed graham cracker crumbs, buttermilk boxes, cheesecake mix, gelatin powder mix and apple sauces with no received date. Observed an open jar of peanut butter and an open bag of cornflakes without a received date, opened date, or use by date. During an interview on 1/8/2023 on 9:02 a.m. with the Dietary Supervisor (DS), in the dry storage food, the DS stated that all items needed to be labeled with the received date, open date, and use by date. The DS stated these items needed to be labeled with these dates to help staff know which items were older, which items needed to be used next, and when the item could no longer be used. During an observation on 1/8/2024 at 9:29 a.m. in the walk-in refrigerator, observed an open bag of sliced carrots with no use by date. Observed open and unopened bags of green grapes that contained spoiled grapes. Observed an undated bag of green peppers. During an observation on 1/8/2023 at 9:41 a.m. at the kitchen's freezer, observed multiple bags of frozen mixed vegetables and multiple bags of frozen broccoli, multiple bags of frozen zucchini, a package of hamburger patties, a bag of bacon, a bag of sausage links, and a bag of waffles with no date indicating when those items were put in freezer. The items were not labeled with a use by date or expiration date. Observed turkey sausages saran wrapped and labeled with the date of 1/5/2024, unable to identify what that date was for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 62 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 - Many During an interview on 1/10/2024 at 11:35 a.m. with the DS, in the kitchen, the DS stated once an item has been opened, it must be dated with the open date and a use by date. During an interview on 11/10/2024 at 11:40 a.m. with the DS, in the walk-in refrigerator, the DS stated the green grapes were spoiled and should not be in the refrigerator. The DS stated it was important not to keep spoiled food in the refrigerator to prevent staff from serving them to residents. During a concurrent observation and interview on 1/10/2024 at 11:48 a.m. with the DS, in the kitchen, the freezer had food items with no dates. The DS stated all food in the freezer must be labeled with the date it was put in the freezer. The DS stated the opened food in the freezer did not have a use by date and stated the items should have been dated. The DS stated there was no way of knowing if the bag of frozen burritos and a frozen bag of raviolis were still good to be served to residents because it did not have an open date and a use by date. The DS stated it was important to accurately date all food items to make sure the facility served unexpired and safe food to the residents. During an observation on 1/10/2024 at 12:15 p.m. in the kitchen, observed the DS removing potentially expired food from the freezer. The DS then went and began checking the temperatures of food that was currently being plated and served to the residents for lunch. The DS did not their wash hands before checking food temperatures. Observed the DS log temperatures on the temperature log form. Observed kitchen staff serving lunch plates for residents and delivering to the floor without first checking food temperatures. During an interview on 1/10/2024 at 12:29 p.m. with the DS, in the kitchen, the DS stated he should have washed his hands before becoming in contact with the resident's food. The DS stated he should have washed his hands before touching the food to prevent food contamination. The DS stated food temperatures were checked by the cook or himself only before plating food. During a review of the facility's policy and procedure (P&P) titled, Refrigerator/Freezer Storage, dated 2019, the P&P indicated leftover food or unused portions of packaged foods should be covered, dated, and labeled to ensure they will be used first. The P&P indicated food items should have the following appropriate dates: Delivery date- upon receipt, Open date- opened containers, and thaw date - any frozen items. During a review of the facility's P&P titled, Daily Food Temperature Control, dated 2019, the P&P indicated the temperature of all hot and cold food shall be taken prior to every meal service and recorded on the temperature log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 63 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 41, 74, and 82) understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) when entering a binding contract by failing to: Residents Affected - Few 1. Present the Arbitration Agreement in a language Resident 82 understood. 2. Ensure Resident 82, Resident 41's Family Member (FM) 1, and Resident 74's Family Member (FM) 2 understood that signing the Arbitration Agreement was not necessary as a condition of admission to the facility. These failures resulted in Resident 82 not understanding in the language he understood and Residents 41, 74, and 82 entering the binding agreement as a pretense that it was mandatory. Findings: a. During a review of Resident 82's admission Record (Face Sheet), the admission Record indicated Resident 82 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), hypertensive heart disease (heart conditions caused by complications of high blood pressure), and heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs). During a review of Resident 82's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 11/17/2023, the MDS indicated Resident 82 was able to understand and be understood by others. The MDS indicated Resident 82's cognition (process of thinking) was intact. During a review of Resident 82's Facility Arbitration Agreement, undated, the Facility Arbitration Agreement indicated Resident 82 signed and entered into the binding agreement. b. During a review of Resident 41's admission Record (Face Sheet), the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus, end stage renal disease (a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41 was able to understand and be understood by others. The MDS indicated Resident 41's cognition was moderately impaired. During a review of Resident 41's History and Physical (H&P), dated 11/8/2023, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Facility Arbitration Agreement, dated 11/28/2023, the Facility Arbitration Agreement indicated FM 1 signed and entered the binding agreement on behalf of Resident 41. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 64 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few c. During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus, heart failure, and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 82's cognition was intact. During a review of Resident 74's H&P, dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Facility Arbitration Agreement, dated 4/11/2022, the Facility Arbitration Agreement indicated FM 2 signed and entered the binding agreement on behalf of Resident 74. During an interview on 1/9/2024 at 10:35 a.m., with Resident 82, Resident 82 stated he spoke primarily Spanish and could understand very little English. Resident 82 stated, When signing important forms, I would like it in Spanish. Resident 82 stated he remembered signing the form; however, he was not told signing was voluntary and he thought he had to sign to continue living at the facility. During an interview on 1/9/2024 at 10:44 a.m., with FM 1, FM 1 stated she understood the binding arbitration agreement, however, when she came to the facility to sign Resident 41's paperwork, she was not told that entering the binding arbitration agreement was not necessary and she felt that she had to sign the agreement for Resident 41 to be admitted to the facility. During an interview on 1/9/2024 at 10:54 a.m., with FM 2, FM 2 stated when he came to the facility to sign paperwork for Resident 74, the staff member who assisted him had given him everything he had to sign. FM 2 stated, They gave me all the paperwork they needed in my mom's record, and I had to sign them. I did not know I did not need to sign the agreement. During an interview on 1/9/2024 at 1:20 p.m., with the Business Office Manager (BOM), the BOM stated when a resident was admitted to the facility, the admission packet was reviewed with the resident and/or their family members. The BOM stated the Arbitration Agreement was available in many languages, including Spanish. The BOM stated Resident 82 was spoke primarily Spanish and should have been provided the Arbitration Agreement in Spanish for him to understand the form and decide if he wanted to enter the binding agreement. The BOM stated the Arbitration Agreement was not mandatory and it was an issue if the residents and family members were under the impression that it was. The BOM stated the Arbitration Agreement was not properly explained. The BOM stated the residents, and their family members had the right to be aware that entering a binding arbitration was not mandatory because if they did not agree with the terms, they would not have to enter it. During an interview on 1/9/2024 at 1:44 p.m., with the Administrator (ADM), the ADM stated the Arbitration Agreement should always be presented to the resident and their family members in the language they understood. The ADM stated Resident 82 should have been presented with the Spanish version of the Arbitration Agreement so he could understand and comprehend the information. The ADM stated the Arbitration Agreement was not mandatory and it was an issue if those who entered into the binding agreement were under the impression that it was mandatory for admission into the facility. The ADM stated everyone should be able to make an informed decision and to understand their options. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 65 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement effective infection prevention measures for three of seven sampled residents (Resident 2, 10, and 46) when the facility failed to: Residents Affected - Few 1. Post signage in and around Resident 2's room to ensure staff providing direct resident care activities were aware of Resident 2's Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). 2. Ensure the Treatment Nurse (TN) performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 46's wound treatment. 3. Ensure Resident 10's enteral hydration (water provided through a feeding tube [a flexible plastic tube placed into the stomach to assist in nutrition and hydration) administration kit (tubing system that delivers the water into the body) was changed within 24 hours. These failures had the potential to result in the transmit of infectious microorganisms and increase the risk of infection. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 12/14/2017 and re-admitted the resident on 5/17/2019 with diagnoses including cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture) and contractures (loss of motion of a joint associated with stiffness and joint deformity). During an observation on 1/10/2024 at 10:19 a.m., in the resident's room, Resident 2 was observed lying in bed. No signage indicating Resident 2 was on ESP was observed above the bed, in the room, on the door, or outside of the room. A pole holding a gastrostomy tube (G-tube, tube inserted through the abdomen that brings nutrition directly to the stomach) machine was observed to the right of Resident 2's bed. A container with drawers containing yellow isolation gowns (protective apparel used to prevent the transfer of microorganisms and body fluids from one person to another) was in the corner of the room against the wall in front of Resident 2's bed. During an interview on 1/10/2023 at 10:40 p.m., Restorative Nursing Aide (RNA) 1 stated she just finished performing exercises to Resident 2's both legs and both arms and applying a splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to the left hand. RNA 1 stated she did not know what type of precautions Resident 2 was on because there was no signage in or around the room to indicate the precaution type. RNA 1 stated she thought Resident 2 might be on ESP precautions because Resident 2 had a G-tube but was unsure. During an interview on 1/10/2023 at 11:08 a.m., Certified Nursing Assistant (CNA) 1 stated he was unsure what type of precautions Resident 2 was on because there was no signage in or around the room to indicate the precaution type. CNA 1 stated he thought Resident 2 might be on ESP precautions or on droplet precautions (procedures to reduce risk of spread of infections transmitted by respiratory droplets generated by coughing, sneezing, talking) but was unsure. CNA 1 stated he only knew (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 66 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 - Few Resident 2 required an isolation gown and gloves for direct resident care activities because he had worked with him several times in the past. CNA 1 stated there was a potential for spreading infection if staff providing direct resident care activities to Resident 2 were not aware he was on precautions. During an interview on 1/10/2024 at 12:32 p.m., the Infection Preventionist Nurse (IPN) confirmed Resident 2 was on ESP precautions but did not have any signage in or around the room to ensure staff providing direct care activities were aware of his precautions. The IPN stated all staff providing any direct care activities to Resident 2 must wear an isolation gown and gloves. The IPN stated ESP precautions were important because it protected the residents from bacteria or viruses that may cause infections (a condition in which bacteria or viruses that care disease enter the body). The IPN stated all residents on ESP precautions should have signage with a number 6 over the resident's bed and signage indicating Enhanced Standard Precautions above the personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) container in the room to ensure staff knew what type of precautions the residents were on and what type of PPE to wear. The IPN stated staff may forget or may not know a resident was on ESP precautions if there was no precaution signage in or around the room which could potentially lead to the spread of infection. During a review of the facility's undated Policy and Procedure (P&P), titled Infection Control, the P&P indicated the facility had established and will maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. 2. During a review of Resident 46's admission Record (Face Sheet), the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) of sacral region (area at the end of the spine), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 12/8/2023, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46's cognition (process of thinking) was intact. The MDS indicated Resident 46 required supervision when rolling left to right on the bed. The MDS indicated Resident 46 had a colostomy (an operation that redirects the colon [large intestine] to a new opening, called a stoma, on the abdomen for the expulsion of stool). The MDS indicated Resident 46 had a Stage IV (4) pressure ulcer (injury to skin and underlying tissue due to prolonged pressure) that was present upon admission. During a review of Resident 46's History and Physical (H&P), dated 9/10/2023, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Order Summary Report, dated 1/9/2024, the Order Summary Report indicated the following daily wound care orders: a. Left posterior (back side) thigh excoriation (skin damage from injury such as scratching or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 67 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 picking at the skin), cleanse with normal saline (NS, solution made of salt and water to cleanse wounds), pat dry, apply Calazime cream (a skin protectant), and cover with bordered gauze. b. Right posterior thigh excoriation, cleanse with NS, pat dry, apply Calazime cream, and cover with bordered gauze. Residents Affected - Few c. Stage IV sacrococcyx (at the area of the tailbone) pressure injury, cleanse with NS, pat dry, apply collagen powder (contains essential building blocks of the skin that assists with wound healing), and cover with bordered foam dressing. d. Colostomy site, cleanse with NS, pat dry, apply colostomy bag (bag that covers the stoma to collect stool). During an observation on 1/9/2024 at 9:02 a.m., with the TN, in Resident 46's room, the TN explained that she would be doing Resident 46's wound treatment. Resident 46 stated she did not have any pain and consented for the TN to continue with the wound treatment. The TN prepared her supplies, performed hand hygiene, and applied new gloves. The TN removed the dressing on Resident 46's left thigh, removed her gloves, and applied new gloves. The TN cleansed the area of the left thigh with NS, patted dry, removed her gloves, and applied new gloves. The TN applied Calazime cream, covered with bordered gauze, removed her gloves, and applied new gloves. The TN removed the dressing on Resident 46's right thigh, removed her gloves, applied new gloves. The TN cleansed the area of the right thigh with NS, patted dry, removed her gloves, and applied new gloves. The TN applied Calazime cream, covered with bordered gauze, removed her gloves, and applied new gloves. The TN removed the dressing on Resident 46's sacrococcyx area, removed her gloves, and applied new gloves. The TN cleansed the area with NS, patted dry, removed her gloves, and applied new gloves. The TN applied collagen powder to the area, removed her gloves, and applied new gloves. The TN covered the area with the padded dressing, removed her gloves, and stated, I was supposed to wash my hands. The TN walked to the sink to perform hand hygiene. During an interview on 1/9/2024 at 9:24 a.m., with the TN, the TN stated she was supposed to perform hand hygiene throughout the wound treatment any time she removed her gloves, removed an old dressing, and moved to a new wound area. The TN stated hand hygiene was done to prevent contamination of other wounds and prevent infection. During an interview on 1/11/2024 at 10:39 a.m., with the Director of Nursing (DON), the DON stated hand hygiene was the number one way to control the spread of infection. The DON stated throughout a wound treatment, the nurse had to perform hand hygiene after removing a dirty dressing, after providing the treatment, before proceeding to the next wound site, and after the conclusion of the treatment. The DON stated there was a potential for cross contamination and infection if hand hygiene was not performed during a wound treatment. During a review of the facility's policy and procedure (P&P) titled, Hand Washing, undated, the P&P indicated, Hand washing must also be performed as follows . in between performance of routine procedures (i.e. [that is] handling urinals, bedpans, catheters, changing dressings, collecting specimens, etc. [et cetera, and other similar things]. During a review of the facility's P&P titled, Infection Control, undated, the P&P indicated, Some situations that require hand hygiene, include . before and after changing a dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 68 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 3. During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with diagnoses included but not limited to type 2 diabetes mellitus dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood). Residents Affected - Few During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 10's cognition severely impaired. The MDS indicated Resident 10 was dependent in eating. The MDS indicated Resident 10 had a feeding tube (a flexible plastic tube placed into the stomach to assist in nutrition). The MDS indicated Resident 10 was on a mechanically altered diet (required change in texture in food or liquids due to difficulty chewing or swallowing). During a review of Resident 10's H&P, dated 3/13/2023, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report, dated 1/7/2024, the Order Summary Report indicated to administer Jevity 1.5 (type of enteral feeding [a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals]) at 45 milliliters per hour (mL/hr, a unit of measurement) for 12 hours. The Order Summary Report indicated for continuous water flush through the enteral tube with 35 mL/hr for 20 hours. During an observation on 1/8/2024 at 9:15 a.m., in Resident 10's room, Resident 10's enteral hydration administration bag was dated 1/4/2024. During an interview on 1/10/2024 at 2:53 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the enteral hydration administration kit was supposed to be changed every 24 hours. LVN 5 stated the hydration tubing was connected to the resident and if the administration kit was hung for over 24 hours, bacteria could grow inside and be transmitted to the resident. LVN 5 stated if the hydration administration kit was dated 1/4/2024, it was hung for four days, which could mean the nurses were opening the bag and refilling the water instead of changing it. LVN 5 stated that was an issue because there would be a higher chance of contamination every time the administration kit would be opened to the air. During an interview on 1/10/2024 at 2:47 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the enteral hydration administration kit was supposed to be changed every 24 hours to prevent infection in the resident. The IPN stated after the administration kit was initially opened and the water poured in, once the water was depleted, the whole system had to be changed. The IPN stated using the same administration kit for four days was an issue because that meant the system was opened multiple times and was exposed to the environment. The IPN stated the potential for contamination increased every time the kit was opened and every day it was not changed. During an interview on 1/11/2024 at 10:45 a.m., with the DON, the DON stated the administration kit was supposed to be changed every 24 hours. The DON stated the administration kit should not have been hung for four days because the whole kit should have been changed when it was empty or when the 24 hours has elapsed, whichever came first. The DON stated cross contamination could have occurred, which had the potential to make the resident sick. During a review of the manufacturer's guideline for the AMSINO AMSure Enteral Administration Kit, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 69 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 the guideline indicated Discard administration set and transition connector when delivery is complete within a maximum of 24 hours . Do not re-use. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 70 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain and calibrate (process that ensures the reading and functionality of a device is accurate and in full working order) the ultrasound/electrotherapy modality machine (medical device that includes both ultrasound, a method to produce high-frequency sound waves that can travel deep into tissue and create therapeutic heat and electrotherapy, a method that sends electrical pulses through the skin) for resident use in the rehabilitation department. Residents Affected - Some This deficient practice had the potential to cause injury to any resident who used this equipment as part of their therapy treatment. Findings: During a concurrent observation and interview on 1/10/2024 at 1:41 p.m., in the rehab gym, the Director of Rehabilitation (DOR) stated the rehab department had one electrical modality machine that provided both ultrasound and electrotherapy treatment. A sticker on the ultrasound/electrotherapy machine indicated the device was last inspected in 6/2022 and was due for reinspection in 6/2023. The DOR stated the ultrasound/electrotherapy machine was supposed to be calibrated yearly and was overdue. During a concurrent observation and interview on 1/11/2024 at 11:00 a.m., in the rehab gym, the Maintenance Director (MD) examined the ultrasound/electrotherapy machine and confirmed the device was due for inspection and calibration on 6/2023. The MD stated the ultrasound/electrotherapy machine should have been calibrated yearly and was overdue. The DOR stated an outside company calibrated the machine and was not sure why it was not done timely. The MD stated it was important the device was maintained and calibrated according to manufacturer's guidelines and recommendations to ensure the device worked properly and did not cause harm to the residents. During a follow up interview on 1/11/2024 at 11:20 a.m., the DOR stated the purpose of calibrating and maintaining equipment routinely and according to manufacturer's recommendations was to ensure the device was safe for resident use and working properly. During a review of the manufacturer's user's manual (revised 9/2008) for the Dynatron Solaris 700 Series ultrasound/electrotherapy machine, the user's manual indicated the calibration process must be performed by a qualified technician using the proper equipment with recommended calibration every six to twelve months. The user's manual further indicated the soundheads (part of the machine that converts energy from one for to another) of the ultrasound device must be calibrated with the device every six months to a year to ensure proper operation and accuracy of the device. During a review of the facility's undated policy and procedure (P&P) titled, Rehabilitation Services, the P&P indicated equipment would be safe and adequate for resident needs and electrical equipment would be calibrated annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 71 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a call light that was maintained in proper working condition and without a frayed cord with inner wires exposed for one out of 24 sampled residents (Resident 69). This deficient practice resulted in Resident 69 using an unsafe call light and the potential to not have needs met. Findings: During a review of Resident 69's admission Record, the admission record indicated Resident 69 was originally admitted to the facility on [DATE] with diagnoses including chronic kidney disease (CKD, gradual loss of kidney function) and benign prostatic hyperplasia (BPH, enlarged prostate gland). During a review of Resident 69's History and Physical (H&P) dated 6/28/2023, the H&P indicated Resident 69 had the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/3/2023, the MDS indicated Resident 69's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 69 required supervision for activities of daily living (ADLs, daily self-care activities such as grooming, personal hygiene, dressing, and toileting). During an interview on 1/8/2024 at 11:18 a.m., in Resident 69's room, Resident 69 stated his call light cord was frayed and he was afraid to use it because he thought it would catch on fire. Resident 69 stated it was not safe to have him use the call light because the inner cables were exposed. Resident 69 stated had notified staff about the frayed cord and staff told him it was ok because the call light still worked. Resident 69 stated staff did not want to help him because they said the call light still worked but the call light sometimes did not work. Resident 69 stated he wanted the call light replaced because it was unsafe and because the call light did not work all the time. During an observation on 1/9/2024 at 9:06 a.m. in Resident 69's room, Resident 69's call light cord was observed frayed and attached to the resident's bed. During an observation on 1/10/2024 at 2:32 p.m. in Resident 69's room, Resident 69's call light cord was observed frayed and attached to the resident's bed. During an interview on 1/11/2023 at 10:14 a.m. with the Maintenance Supervisor (MS), the MS stated he did resident room rounds every day. The MS stated he checked residents call lights every day because that was part of his job. The MS stated that he was not aware that Resident 69's call light cord was frayed. The MS stated nurses report items to be repaired in the maintenance logbook and he did not see that Resident 69's call light needed to be replaced. The MS stated it was important to have all residents with a call light in a good condition. During a concurrent observation and interview on 1/11/2024 at 11:38 a.m. with the MS and Resident 69, in Resident 69's room, Resident 69's call light cord was frayed. The MS stated he had checked on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055170 If continuation sheet Page 72 of 73 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 055170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 69's call light every day that week and did not see the frayed cord and he had checked that the call light worked. Resident 69 stated the call light did not work all the time and there were times where it did not work. The MS stated he did not know it was not working. During a review of the facility's policy and procedure (P&P) titled, Resident and Medical equipment Check, undated, the P&P indicated the purpose of the policy was to have staff make routine resident and environment checks to help maintain resident safety and well-being. The P&P indicated the maintenance department will check medical equipment such as call lights. Event ID: Facility ID: 055170 If continuation sheet Page 73 of 73