Health inspection·November 18, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Indwelling Catheter, LVN 1 stated the care plan indicated monitoring intake and output as per policy. LVN 1 stated there was no care plan developed for the foley catheter on 10/3/2025. The facility should have developed and implement the care plan when the foley was inserted on 10/3/2025. During an interview with LVN 1 on 11/17/2025 at 8:15 AM, LVN 1 stated Resident 1 requested a foley catheter. The nurse called and informed the primary medical doctor (PMD) regarding Resident 1's request, and the PMD gave an order to insert foley catheter. LVN 1 stated the order indicated that if the output was greater than 300 ml the Foley would remain in place. During an interview on 11/17/2025 at 10:16 AM with LVN 2, LVN2 stated Resident 1's order for Foley catheter did not include an indication. LVN 2 also stated we cannot just insert Foley without indication due to high risk for infection. During a concurrent interview and record review on 11/17/2025 at 10:29AM with the Director of Nursing (DON), of the facility's P&P titled Indwelling (Foley) Catheter insertion, Female Resident the DON stated the P&P indicated the following under Documentation:The date and time the procedure was performed.The indication(s) for catheter use.The name title and title of the individual(s) who perform the procedure.All assessment data (example (e.g., urine character, color, clarity, etcetera (etc., used at the end of a list to indicate that further similar items are included) obtained during the procedure.The size of the catheter inserted, and the amount of sterile water used to inflate the balloon.How the resident tolerated the procedure. The DON stated the P&P was not followed for Resident 1's Foley catheter insertion. There was no indication documented for the catheter, no documentation completed on the time of insertion, and no monitoring of input and output for Resident 1's in the progress notes. The DON stated the Foley catheter order did not include the indication and the foley catheter was requested by Resident 1. During a concurrent interview and record review on 11/17/2025 at 10:30AM with the DON, the facility's P&P revised dated 3/2022, titled Care Plan, Comprehensive Person-Centered, The DON stated the P&P indicated a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Event ID: Facility ID: 055376 If continuation sheet Page 2 of 5 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 055376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007 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 - Some 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 maintain the physical environment in a safe and sanitary condition by failing to ensure there was no water leak in the facility ceiling from 11/15/2025 to 11/18/2025 by failing to:Ensure there was no water leak in the ceiling at the hallway in front of the oxygen room from 11/15/2025 to 11/16/2025.Ensure there was no water leak in the ceiling of Resident 4's room.This deficient practice had the potential to cause harm by creating slip hazards, increase the risk for mold growth and compromise the safety and comfort of residents, staff and visitors. Findings: 1. During an observation of the facility's ceiling in the hallway in front of oxygen room on 11/17/2025 at 6:33 AM, the ceiling was observed with a large hole with visible water damage. The water leaked from the damaged area, into a large gray bin that was placed underneath to catch the water. Towels were placed on the floor around the large gray bin.During a concurrent interview on 11/17/2025 at 9:56 AM with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated the water leakage started when it started to rain on 11/15/2025 to 11/16/2025. The ADM also stated the maintenance assistant (MTA) was sick, and the maintenance supervisor was on leave. But they are fixing the roof now 11/17/2025. During an interview on 11/17/2025 at 11:32 AM with MTA, MTA stated he was fixing the roof today, as he was informed last Saturday 11/15/2025. During a concurrent observation, interview and record review on 11/17/2025 at 12:30 PM, the License Vocational Nurse (LVN 2), LVN 2 stated the ceiling in front of the oxygen room had peeling paint and a hole in the ceiling with visible water damage. LVN 2 also stated a large gray bin was placed underneath to catch the rainwater. On the floor there were towels around the large gray bin to absorb any rainwater that did not fall into the large gray bin. LVN 2 also stated the facility should not have leaks and it was dangerous. LVN 2 stated the building should be in good repair and free of hazards for the safety of staff and residents in accordance with the facility's policy and procedures (P&P) titled Maintenance Services. During an interview on 11/17/2025 at 1:00 PM with MTA, MTA started there was a quarter size hole in the roof that caused the leakage in the hallway in front of the oxygen room. During a review of the facility's P&P titled Maintenance Service revised date 12/2009, indicated maintenance service shall be provided to all areas of the building, ground and equipment. The P&P also indicated the maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe operational manner at all times. 2. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE] and re-admit 10/15/2025. Resident 4's diagnoses included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in the body tissues) and generalized muscle weakness. During a review of Resident 4's Minimum Data Set (MDS, resident assessment tool), dated 10/1/2025, the MDS indicated Resident 4 modified independence (some difficulty in new situations only) in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 4 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer, and tub/shower transfer. During a concurrent observation in Resident 4's room and interview on 11/18/2025 at 9:40 AM, Resident 4's ceiling was observed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055376 If continuation sheet Page 3 of 5 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 055376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007 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 - Some grayish colored discoloration. Resident 4 stated his ceiling had water leak last night (11/17/2025 night) and pointed at the ceiling discoloration as watermarks because water was dropping from the ceiling last night. Resident 4 stated some of his personal items on his bedside table were soaked with water from the rain and the water was coming in from the outside through the screen door, and water was seeping through the walls, then Resident 4 pointed the watermarks on the wall and the ceiling. During a concurrent observation and interview on 11/18/2025 at 9:42 AM, with Registered Nurse Supervisor 1 (RNS 1) inside Resident 4's room, RNS 1 looked at Resident 4's ceiling and saw the grayish colored discolorations on the ceiling and wall. RNS 1 stated there was a leak in a resident's room, and it is a safety issue. RNS 1 stated Resident 4 can also get wet from the water leaking from the ceiling. During a concurrent observation and interview on 11/18/2025 at 9:47 AM with Maintenance Assistant (MTA) inside Resident 4's room, MTA was looking at the ceiling with watermarks and stated those are water marks from the leak on the roof. MTA stated there was a leak inside the resident's room, and the resident might get wet, and the resident may not be able to sleep. MTA also stated the water leak from the roof can have water damage on the ceiling, and the ceiling can fall off on the resident. MTA also stated he just heard about the issue right now, and the staff did not communicate that there was a leak inside the resident's room. MTA was not aware about the Maintenance Log Binder. During a concurrent interview and record review on 11/18/2025 at 9:56 AM with Licensed Vocational Nurse 4 (LVN 4), the facility's Maintenance Request Form (MTF) was reviewed. The MTF did not indicate any report for the month of 11/2025. LVN 4 stated there was no log dated yesterday (11/17/2025) regarding the leak in Resident 4's room. LVN 4 stated, the previous nurse from the previous shift did not endorse anything regarding leaking ceilings inside Resident 4's room. LVN 4 also stated if there was a leak in a resident's room, they would have to move the resident to another room to make sure the resident's health condition is not going to be affected because the resident can possibly get wet and residents can get sick. During a concurrent interview and record review on 11/18/2025 at 9:57 AM with RNS 1, the facility's MTF was reviewed. RNS 1 stated there was no log or documentation in the MTF for yesterday's incident of water leak inside resident 4's room and it meant nothing was reported by the staff. RNS 1 stated it will be a resident safety issue if there is a leak inside a resident's room. During an interview on 11/18/2025 at 10:02 AM with MTA, MTA was not aware of the Maintenance Log Binder in the nurses' station and MTA did not check it today. MTA stated he was supposed to check the Maintenance Log Binder every day to check if there is equipment or ceiling that needs to be repaired. During a concurrent interview and record review on 11/18/2025 at 10:03 AM, MTA stated, MTA checked the Tels application (a new online application used by the facility staff for maintenance report) and the staff can send the maintenance report in the computer. The Tels app showed zero (0) on the report section dated from 11/17/2025 to 11/18/2025. MTA stated zero (0) means that there was nothing reported in the application, and it means the staff did not log/ report the leak in Resident 4's room that started on 11/17/2025 at night. During an interview on 11/18/2025 at 1:05 PM with the Director of Nursing (DON), the DON stated the facility staff should have notified the MTA right away as soon as the facility staff noted the leak in Resident 4's ceiling. The DON stated, if the ceiling was leaking inside a resident's room, staff should have completed a room change for the affected resident(s), and the staff toned to make sure that the resident's space is clean and safe for the resident. During a concurrent interview and record review on 11/18/2025 at 1:15 PM with the DON, the facility's policy and procedure (P&P) titled, Work Orders, Maintenance revised 4/2010, was reviewed. The P&P indicated, Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily. The DON stated the facility staff should have filed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055376 If continuation sheet Page 4 of 5 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 055376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete report on the Maintenance Log Binder and reported it to the Maintenance Assistant. During a review of the facility's policy and procedure (P&P) titled, Work Orders, Maintenance revised 4/2010, the P&P indicated Maintenance work orders shall be completed to establish a priority of maintenance service.1. To establish priority of maintenance services, work orders must be filled out and forwarded to the maintenance director.2. A supply of work orders is maintained at each nurses' station. During a review of the facility's P&P titled, Homelike Environment, revised 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Event ID: Facility ID: 055376 If continuation sheet Page 5 of 5