Health inspection·August 15, 2025

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was reviewed. The P&P indicated acceptable serving temperatures are not limited to the following: Casseroles - More than 140 degrees Fahrenheit Pasta - More than 140 degrees Fahrenheit Vegetables More than 140 degrees Fahrenheit Milk, Juice - Less than 41 degrees Fahrenheit Quality Assurance Nurse (QAN) stated the serving temperatures means the required temperature of food when the food gets/ is served to the residents. During a concurrent interview and record review on 8/15/2025 at 3 PM, the P&P titled Food Temperatures, revised 1/31/2019, was reviewed. Administrator (ADM) stated the serving temperatures mean when the food gets to the residents. ADM also stated the pasta and carrots served to Resident 2 for lunch today did not meet the serving temperatures. During a review of the P&P titled Food Temperatures, revised 1/31/2025, the P&P indicated if temperatures do not meet the required serving temperatures listed above, reheat the product or chill the product to the proper temperature. Event ID: Facility ID: 055293 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780 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 Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated in the facility's policy and procedure by failing to ensure:1. Licensed Vocational Nurse 1 (LVN 1) doff (remove an item or clothing) Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (the process of cleaning one's hands to remove dirt, germs, and other microorganisms. It involves washing hands with soap and water or using alcohol-based hand rubs) prior to exiting Room B.2. Physician 1 don (putting on an item or clothing) on an N-95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) prior to entering Unit A (the COVID [Coronavirus Disease- a highly contagious respiratory disease caused by the SARS-CoV-2 virus. SARS-CoV-2 is thought to spread from person to person through droplets released when an infected person coughs, sneezes, or talks] unit).3. The Unit Manager (UM) wears the N-95 mask correctly covering the mouth and nose while in Unit A.4. Dietary Supervisor Assistant (DSA) change gloves and performs hand hygiene after picking up a bowl from the floor and before continuing with tray line (a healthcare food service assembly line where food trays are prepared by passing through a series of stations, each performing a specific task like adding cold items or hot food, to ensure efficient and accurate meal delivery to residents). 5. Dietary Staff (DTS) did not pick up a bag of bowl lids from the floor and put it on tray line near the ready-to-eat foods. These deficient practices had the potential to spread infection to staff and residents.Findings:1. During a concurrent interview and record review of the facility's floor plan on 8/15/2025 at 10:12 AM, Infection Preventionist Nurse (IPN) stated an N-95 mask should always be worn in Unit A (the COVID 19 Unit). IPN also stated when going into the resident's room in Unit A, PPE should be worn before entering the room and PPE should be removed/ doff before leaving the room. IPN stated there is signage posted and mask available outside of unit A outlining infection control protocols. IPN stated the red marking indicated on the floor plan means unit A is a COVID-19 unit. During a concurrent observation and interview on 8/15/2025 at 10:43 AM, LVN 1 was observed rolling a used gown outside of Room B, went back in Room B to dispose of the used gown and left Room B without performing hand hygiene. LVN 1 stated LVN 1 should have but did not remove his gown and performed hand hygiene prior to exiting Room B. LVN 1 stated it is not okay because it can spread infection to staff and other residents. During an interview on 8/15/2025 at 10:47 AM, IPN stated hand hygiene and donning of PPE should occur prior to entering the resident's room who is on isolation precautions (set of infection control measures designed to prevent the spread of infectious diseases in healthcare settings), and doffing of PPE and performing hand hygiene should occur before exiting the resident's room who is on isolation precaution. IPN stated with the indication of a mask already worn since Room B is in Unit A, the donning of PPE should be done as follow: perform hand hygiene, don gown, and don gloves before entering a resident's room, and doffing should be done as follows: doff gloves, doff gown and perform hand hygiene before exiting a resident's room. 2. During a concurrent observation and interview on 8/15/2025 at 12PM in Unit A, Physician 1 was noted without an N95 mask. Physician 1 was also observed walking up and down the hallway of Unit A twice without a mask/N-95 on. Physician 1 stated he forgot to put his mask on while in Unit A. 3. During a concurrent observation and interview on 8/15/2025 at 12:30 PM in Unit A, Unit Manager (UM) was observed with his N95 mask under placed under his chin not covering UM's mouth or nose. UM stated he was not wearing his N95 mask on correctly to ensure his mouth and his nose were covered. A review of the facility's P&P titled Personal Protective Equipment, revised 7/1/2023, the P&P indicated the facility will wear an N-95 to follow their respiratory protection Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055293 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete program. The P&P also indicated when gowns are used, they are used only once and discarded into appropriate receptacle located in the room in which the procedure is performed. A review of the facility's P&P titled Categories of Transmission-Based Precautions Resident isolation, revised 7/1/2023, the P&P indicated the gown is removed, and hand hygiene is performed before leaving the resident's environment. A review of the facility's P&P titled Infection Prevention and Control Program, revised 10/24/2025, the P&P indicated it is intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of the facility's P&P titled Hand Hygiene, revised 2/20/2025, the P&P indicated hand hygiene should be done immediately upon entering a resident occupied area and immediately upon exiting a resident occupied area. A review of the facility's P&P titled COVID-19 and Quarantine, revised 7/1/2025, the P&P indicated staff will be required to wear masks when there is an outbreak in the facility and appropriate PPE when care for a resident. A review of the Centers of Disease Control Guidelines How to use your N95 Respirator, dated 3/12/2025, the guidelines indicated when putting on an N95 Respirator, the respirator should be placed under the chin with the nose piece bar at the top with the nose piece mold to the shape of your nose and it should fit snugly. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-face-m 4. During a concurrent observation on 8/15/2025 at 12 PM in the kitchen with Dietary Supervisor (DS) present, the tray line was observed. Dietary Supervisor Assistant (DSA) was observed dropping a bowl of food from the refrigerator, then picking it up and continuing the tray line with the same contaminated gloves. During an interview on 8/15/2025 at 12:10 PM in the kitchen, DS stated DSA should have changed gloves and perform hand hygiene after picking up the bowl from the floor and before touching anything in the kitchen/ continuing the tray line. DS also stated not changing gloves and performing hand hygiene is not okay because it can spread infection. 5. During an observation on 8/15/2025 at 1:18 PM in the kitchen, tray line was observed when Dietary Staff (DTS) dropped a bag of bowl lids. DTS was observed picking up the bag of bowl lids, put it on the tray line near the ready-to-eat foods and touched the tray line with the same contaminated gloves. During an interview on 8/15/2025 at 1:20 PM in the kitchen during tray line, Registered Dietician (RD) stated DTS should have changed DTS' gloves and performed hand hygiene before continuing to work on the tray line because that can spread infection to the residents. DTS also stated, the bag of bowl lids that was picked up from the floor by the DTS should not be placed on the tray line and/ or near the ready-to- eat food items to avoid contamination of food served to the residents. A review of the facility's Policy and Procedure (P&P) titled Food Storage, revised 6/1/2017, the P&P indicated wash hands before handling food and keep work surfaces clean and orderly. A review of the facility's P&P titled General Dietary Department, revised 10/24/2022, the P&P indicated staff should wear intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. A review of the facility's P&P titled Hand Hygiene, revised 2/20/2025, the P&P indicated washing hands with soap and water before and after food preparation and before direct contact with food. Event ID: Facility ID: 055293 If continuation sheet Page 4 of 4