Health inspection·February 6, 2026

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dignity and privacy for two of three sampled residents (Resident 2 and Resident 3).This deficient practice had the potential to affect Resident 2's and Resident 3's psychosocial wellbeing. a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/27/2020, with diagnoses that included (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognitive status (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff with shower/bath, toileting and personal hygiene. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 10/6/2025, with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions]) and a history of falling. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated was dependent on staff with shower/bath and toileting hygiene. During an observation on 2/5/2026 at 8:37 AM to 8:48 AM inside Resident 2's room, Certified Nursing Assistant 1 (CNA 1) prepared a basin with water, towels and soap. CNA 1 removed the blanket that was covering Resident 2, removed Resident 2's gown and then removed Resident 2's diaper. Resident 2's whole body was exposed as CNA 1 started to wipe Resident 2's face, chest, left arm, neck, right armpit, right arm and then the fingers. At 8:48 AM, while Resident 2 was uncovered, CNA 1 opened the privacy curtain surrounding Resident 2's bed and the door to Resident 2's room was wide open. With the curtain slightly open, Resident 2's exposed body could be seen through the open doorway. During an observation on 2/5/2026 at 9:33 AM to 9:50 AM, CNA 2 prepared supplies for a bed bath, closed the privacy curtain around Resident 3's bed, removed the blanket which covered Resident 3 then removed Resident 3's gown. CNA 2 cleaned Resident 3's face, right armpit, right arm, perineal area and cleaned Resident 3's buttocks. Resident 3's roommate opened the privacy curtain surrounding Resident 3's bed while Resident 3's whole body was exposed. CNA 2 did not cover Resident 3 and did not close Resident 3's privacy curtain after Resident 3's roommate opened the privacy curtain. CNA 2 continued to provide care to Resident 3, applied powder to Resident 3's groin area and fastened Resident 3's diaper. During a concurrent observation and interview on 2/5/2026 at 9:50 AM with Resident 3, Resident 3 stated Resident 3 felt upset since Resident 3 could not have privacy. Resident 3 asked CNA 2 to close the privacy curtain surrounding Resident 3's bed. During an interview on 2/6/2026 at 9:38 AM, CNA 1 stated staff (in general) must cover residents during a bed bath to provide privacy. CNA 1 stated CNA 1 forgot to cover Resident 2 when CNA 1 bathed Resident 2 in bed on 2/5/2026. During an interview on 2/16/2026 at 10:12 AM, CNA 2 stated residents (in general) must be covered during a bed bath so the resident's whole body would not get exposed and feel uncomfortable. During a review Residents Affected - Few Page 1 of 4 055259 055259 02/06/2026 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0583 Level of Harm - Minimal harm or potential for actual harm of the facility's Policy and Procedure (P&P) titled Bath, Bed, dated March 2021, the P&P indicated residents must not be exposed and must be covered with a bath blanket and kept covered as much as possible during the bed bath. During a review of the facility's P&P titled Resident Rights, dated December 2021, the P&P indicated all residents of the facility have the right to a dignified existence, to privacy and confidentiality. Residents Affected - Few 055259 Page 2 of 4 055259 02/06/2026 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 ensure: 1. Certified Nursing Assistant (CNA) 3 changed gloves after transferring Resident 4 back to bed and before preparing supplies and handling clean linens and diaper for Resident 4's diaper change on 2/4/2026. 2. CNA 1 and CNA 2 changed wash cloths and bath water prior to providing Resident 2 and Resident 3 perineal care on 2/5/2026. These deficient practices had the potential to spread bacteria that could lead to urinary tract infection.Findings: 1.During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 5/30/2025, with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked which causes the urine to back up and injure one or both kidneys), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 4 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation on 2/4/2026 at 1:44 PM to 1:56 PM, Certified Nursing Assistant (CNA) 3 and CNA 4 performed hand hygiene at the door and put gloves on prior to entering Resident 4's room. CNA 3 and CNA 4 transferred Resident 4 from the geriatric chair to the bed. CNA 3 took towels from the cabinet located at the foot of Resident 4's bed and went to the bathroom and placed the towels on top of the table on the left side of Resident 4's bed without changing gloves. CNA 3 checked Resident 4's diaper and then closed the sliding door, opened the top drawer of a cabinet located at the foot of Resident 4's roommate bed and took out a bottle of body wash from the top drawer. CNA 3, using the same gloves, squeezed body wash onto the wet towel, wiped the perineal area of Resident 4, turned Resident 4 to the left side and wiped the bottom then put on a new diaper on Resident 4. CNA 3, using the same gloves, opened the top drawer of the same cabinet located at the foot of Resident 4's roommate and took a sheet from inside the drawer and touched the items inside the drawer while pulling out a sheet used to cover Resident 4. During an interview on 2/4/2026 at 2:51 PM with CNA 3, CNA 3 agreed CNA 3 did not change gloves after transferring Resident 4 back to bed and before preparing supplies and handling clean linens and diaper for Resident 4's diaper change on 2/4/2026. During a review of the facility's Policy and Procedure (P&P) titled Standard Precautions, dated September 2022, the P&P indicated, Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces. 2a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/27/2020, with diagnoses that included (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognitive status (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff with shower/bath, toileting and personal hygiene. 2b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 10/6/2025, with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions]) and a history of falling. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated was dependent on staff with shower/bath and toileting hygiene. During an observation on 2/5/2026 at 8:37 AM, CNA 1 donned PPE (gown and gloves) prior to entering Resident 2's room. CNA 1 brought one basin of water to the Residents Affected - Few 055259 Page 3 of 4 055259 02/06/2026 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room, squeezed body wash to the water, removed the blanket, gown and diaper then started cleaning Resident 2 in this order: the face, chest, left armpit, left arm, neck, right armpit, right arm and the fingers rinsing the towel into the water before moving to other areas of the body. CNA 1, using the same water, washed the left leg, right leg, perineal area, the back and then the buttocks area. During an observation on 2/5/2026 at 9:33 AM, CNA 2 prepared the supplies then put gloves on, and brought a bucket of water into Resident 3's room. CNA 2 removed the blanket and gown covering Resident 3. CNA 2 used one small, wet towel to clean the face, right armpit, right arm, left armpit, left arm rinsing the towel into the water before moving to different areas of the body. CNA 2 used the same water to rinse the towel, squeezed body wash to the towel and cleaned the perineal area. CNA 2 poured water from the basin into the perineal area, then dry the area with a big towel. CNA 2 squeezed body wash to the towel and cleaned the buttocks area. During a review of the facility's P&P titled Bath Bed dated March 2021, the P&P indicated the steps in the procedure were to wash the face, ears and neck, the arms and hands, chest and abdomen, change the bathwater, wash the legs and feet, change the bathwater, wash the back and buttocks, change the bathwater before washing the perineal area using the following steps:Perineum:a. Wash, rinse well, and dry the genital and anal areas.b. Always wash the anal area last to avoid contaminating the urinary tract with fecal matter.c. If the resident can perform this task, he/she may do so. Allow for privacy at all times. During a review of an article taken from the National Institute of Health titled Assisting Patients with Personal Hygiene dated September 26, 2022, the articled indicated when cleaning the genital area of a patient, roll the patient onto their side. Make sure to use disposable wipes and wipe from front to back when cleaning the genitals. This process prevents urinary tract infections. Immediately dispose used wipes in the plastic waste bag. If disposable wipes are unavailable, use new cloths and fill the basin with clean water. 055259 Page 4 of 4