Health inspection·August 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete respectful. ? During an interview on 8/26/2025 at 3:50 PM, CNA 3 stated she was assigned to Resident 3 on the night shift of 8/21/2205. CNA 3 stated she told Resident 3 she would be providing her incontinent care, but the resident refused. CNA 3 stated she could not leave Resident 3 wet, so she insisted she needed to be changed and Resident 3 resisted. CNA 3 stated she did not think of leaving Resident 3 alone or calling for another nurse or translator to further understand or explain clearly to Resident 3. CNA3 stated she should not have provided care at that time if Resident 3 said she did not want it. ? During an interview on 8/27/2025 with LVN 3 at 12:14 PM, LVN 3 stated Resident 3's primary language was Spanish, and she was able to make her needs and wants known. LVN 3 stated according to facility policy, Residents have a right to refuse care and if Resident 3 refused ADL care, the staff should have acknowledged the resident's wants and went back later to offer ADL assistance and should have informed the LVN charge nurse. LVN 3 also stated that not honoring the residents' rights can upset them and can make them distrust staff there to help them. ? During an interview on 8/27/2025 at 4:03 PM with CNA 4, CNA 4 stated Resident 3 spoke Spanish and able to let staff know if she wanted incontinence care provided at that time. CNA 4 stated during the night shift on 8/22/2025, Resident 3 informed her CNA 3 was rough with care and not listening or trying to understand her while providing incontinent care. ? During a concurrent interview with the Director of Nursing (DON) and record review on 8/27/2025 at 5:00 PM, the facility's policy & procedure (P&P) titled Resident Rights- Quality of Life, implemented 5/1/2023, the P&P indicated the purpose to ensure all residents are treated with the level of dignity they are entitled to while residing at the facility. The P&P also indicated facility staff speak respectfully to residents at all times and staff treats cognitively impaired residents with dignity and sensitivity. The DON stated per policy, dignity and respect are to be given to every resident and speaking respectfully?means using a normal time of voice, respectful tone, explaining to the resident what is to be done, and ensure culture and language differences are honored. The DON also stated, if a resident is refusing care, staff should never force a resident to do comply but educate them, inform the charge nurse and return later to ensure the care is provided. ? During a review of the facility's P&P titled Resident Rights, revised 10/1/2017, the P&P indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. ? During a review of the facility's P&P titled Privacy and Dignity, revised 6/1/2017, the P&P indicated staff assists the resident in maintaining self-esteem and self-worth, residents are groomed as they wish to be groomed and staff treats residents with respect including respecting their social status, speaking respectfully, listening carefully. 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 08/27/2025 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 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** Based on interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 2), was assessed and monitored for 72 hours after an alleged incident episode of physical abuse (an intentional act causing injury or trauma to another person through bodily contact) as indicated in the facility's policy and procedure (P&P). This failure had the potential for Resident 2 not to be monitored for physical and/or psychosocial changes negatively affecting his overall well-being. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive?(a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities) and weakness. ? During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 7/30/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills?(mental action or process of acquiring knowledge and understanding)?for daily decision making. The MDS also indicated Resident 2 was substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating, oral, personal and toileting hygiene and dependent (helper does all effort needed to complete activity) with shower/bathing and lower body dressing. ? During a review of Resident 2's Change in Condition (COC- a significant alteration in a patient's physical, mental, or functional status) Evaluation, dated 8/24/2025, the COC indicated an alleged incident of physical abuse toward Resident 2 by Certified Nurse Assistant 3 (CNA 3). ? During a review of Resident 2's Risk for Emotional Distress related to Allegations of Abuse care plan?(a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs), initiated 8/24/2025, the care plan indicated interventions to assess emotional status regularly. ? During an interview on 8/26/2025 at 11:18 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated there was an allegation of abuse towards Resident 2 on 8/24/2025 and nursing monitors his mental and physical health for 72 hours as indicated on the facility's COC policy. ? During a concurrent interview and record review on 8/26/2025 at 11:26 AM with LVN 2 and Registered Nurse 2 (RN 1), Resident 2's electronic and physical medical chart was reviewed. The medical charts failed to indicate any monitoring of Resident 2's condition on 8/25/2025 during the day shift (7 AM through 3 PM), evening shift (3 PM through 11 PM) and night shift (11 PM through 7 AM). RN 1 stated there is no evidence of monitoring documented for Resident 2 after the COC. RN 1 stated the licensed nurses should have monitored and documented Resident 2's condition for each shift on 8/25/2025. LVN 2 stated it is important to assess and monitor Resident 2 for 72 hours because Resident 2 cannot verbalize changes so staff would not become aware of any new changes without monitoring. ? During an interview on 8/26/2025 at 1:40 PM with the Director of Staff Development (DSD),?the DSD stated?72-hour monitoring is done to monitor changes in condition (improving or worsening), documentation is done in the electronic chart under nurses' notes and is completed every shift. ? During an interview on 8/27/2025 at 12:14 PM with LVN 3, LVN 3 stated Resident 2 had a change in condition for an alleged instance of abuse and per facility policy, 72-hour monitoring by a nurse each shift should have been done to monitor for bruising, injuries or pain that Resident 2 may develop. LVN 3 stated Resident 2 has confusion and may be unable to verbalize changes, and if monitoring is not done, staff will not be aware of changes which could lead to Resident 2 experiencing neglect?(fail to care for properly). ? During an interview on 8/27/2025 at 5PM with the Director of Nursing (DON), the DON stated that according to the facility policy, staff should have completed the 72-hour monitoring for Resident 2, to ensure he was not in distress, there are no Residents Affected - Few (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 08/27/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm injuries and there are no additional changes in his condition. ? During a review of the facility's P&P titled Change of Condition Notification, revised 6/1/2017, the P&P indicated the purpose to ensure residents, family, legal representatives and physicians are informed of changes in the resident's condition in a timely manner and a licensed nurse will document each shift for at least 72 hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055293 If continuation sheet Page 4 of 4