Health inspection·April 30, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MDS 1 indicated Resident 1 was frequently incontinent of urine (loss of bladder control). MDS 1 indicated Resident 1 was dependent on staff for most self-care activities and required maximal/substantial assistance with mobility and transfers. During an interview on 4/26/2024 at 11:04 AM, Resident 1 stated he wanted to get OOB earlier that day, but he had to wait until 10 AM because there was no staff to assist him. Resident 1 stated he has verbalized his concerns to the staff before. Resident 1 stated, They don't have enough staff. CNAs are overworked. During an interview on 4/26/2024 at 11:49 AM, CNA 4 stated due to the staffing shortage, CNA 4 was able to change the residents' incontinence brief twice per shift-one in the morning and one in the afternoon. CNA 4 stated changing and turning/repositioning of residents must be done every two hours and as needed for all residents. CNA 4 stated when answering call lights, some residents would get mad because of waiting for a long time because CNA 4 was busy with providing care to another resident. During an interview on 4/26/2024 at 1:09 PM, CNA 6 stated due to the staffing shortage, CNA 6 could not answer the call lights in a timely manner. CNA 6 stated CNA 6 would change the residents' incontinence brief twice per shift-in the morning and after lunch. CNA 6 stated CNA 6 could go not back to the resident room to change and reposition/turn the resident at least every two hours as required. CNA 6 stated some staff are not able to take their breaks due to the busy workload. During an interview on 4/26/2024 at 1:28 PM, CNA 7 stated due to the staffing shortage, call lights were not answered because CNAs were busy providing care to the other residents. CNA 7 stated CNA 7 would change residents' incontinence brief twice per shift and turning/repositioning was done only for the people who really needed it. CNA 7 stated all residents must be changed and turned/repositioned at least every two hours and as needed. During a review of the facility's policy and procedure (P&P 1), titled Answering the Call Light (undated), P&P 1 indicated the facility must ensure timely responses to the resident's requests and needs when answering the call light. P&P 1 indicated the staff must answer the resident call system immediately. P&P 1 indicated if the resident's request could be fulfilled, the task must be completed within 5 minutes, if possible. P&P 1 indicated if it was uncertain whether or not the request could be fulfilled, the nurse supervisor must be asked for assistance. During a review of the facility's policy and procedure (P&P 2), titled Activities of Daily Living, Supporting, dated 2018, P&P 2 indicated the following: 1. Residents must be provided with care, treatment, and services as appropriate and in accordance with the plan of care to maintain or improve their ability to carry out ADLs. 2. Residents who are unable to carry out ADLs independently must receive the services necessary to maintain good nutrition, grooming, and personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 2 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interviews and record review, the facility failed to develop and implement an individualized care plan for six of 15 sampled residents (Residents 7, 9, 10, 11, 13, & 14) in accordance with the physician's orders by failing to: A. Ensure there was a physician's order for the intervention Assisted Active Range of Motion (AAROM, joint receives partial assistance from an outside force) exercises to both lower extremities (BLEs) in Resident 7's care plan. B. Perform Passive ROM (PROM, outside force exclusively causes joint movement) exercises to Resident 9's right upper extremity (RUE) as indicated in the care plan. C. Perform PROM exercises to Resident 10's BLEs and RUE as indicated in the care plan. D. Perform PROM exercises to Resident 11's BLEs as indicated in the care plan. E. Perform Active ROM (AROM, effort to move the body part without outside help or force) exercises to Resident 13's BLEs as indicated in the care plan. F. Apply Resident 14's left elbow splint (device applied to support the extremity in the best position while resting) and perform PROM exercises to Resident 14's LUE as indicated in the care plan. These failures had the potential to diminish the residents' quality of life related to a further decline in the residents' physical and psychosocial well-being. (Cross reference with F688) Findings: A. During a review of Resident 7's AR (AR 7), AR 7 indicated the facility initially admitted Resident 7 on 10/18/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interfere with daily activities) and morbid obesity (severely overweight). During a review of Resident 7's H&P (H&P 7), dated 10/19/2023, H&P 7 indicated Resident 7 had worsening confusion. H&P 7 indicated Resident 7 did not have the capacity to understand and make decisions. H&P 7 indicated Resident 7 required assistance with mobility and personal care. During a review of Resident 7's MDS (MDS 7, standardized resident assessment and care-planning tool), dated 1/19/2024, MDS 7 indicated Resident 7 had moderate impairment in cognition (ability to think, remember, and reason). MDS 7 indicated Resident 7 had an impairment in both lower extremities. MDS 7 indicated Resident 7 was dependent on staff for most self-care activities and transfers. During a review of Resident 7's care plan (CP 7) for Resident 7's risk for falls related to the lack of coordination (initiated on 10/15/2018), CP 7 indicated the following interventions were added on 1/30/2024: 1) RNA Program; AAROM exercises on BLEs every day five times a week or as tolerated every day shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 3 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 7's Order Summary Report (OSR 7) for 4/2024, OSR 7 indicated the following active physician's order for RNA services: Residents Affected - Some 1) Order Date: 3/1/2024 - RNA Program: Apply multi-podus boot (device used to eliminate pressure or friction on the heel to prevent sores) to left and right feet 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During an interview on 4/30/2024 at 3:44 PM, the Director of Nursing (DON) stated the residents' care plans must be developed and revised to reflect the RNA orders to ensure all staff implement the care plan and provide the RNA services consistently. B. During a review of Resident 9's AR (AR 9), AR 9 indicated the facility initially admitted Resident 9 on 3/17/2021 with multiple diagnoses that included a history of cerebral infarction (stroke, brain damage due to blocked blood supply to the brain), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and dementia. During a review of Resident 9's H&P (H&P 9), dated 8/13/2023, H&P 9 indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's MDS (MDS 9), dated 3/21/2024, MDS 9 indicated Resident 9 had severe impairment in cognition. MDS 9 indicated Resident 9 was dependent on staff for most self-care activities and mobility. During a review of Resident 9's OSR (OSR 9) for 4/2024, OSR 9 indicated the following active physician's order: 1) Order Date: 3/1/2024 - RNA Program: PROM exercises to right upper extremity five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a review of Resident 9's care plan (CP 9) regarding ADL self-care performance deficit (initiated on 5/9/2019), CP 9 indicated the following intervention was initiated on 3/1/2024: 1) RNA Program: PROM exercises to RUE five times a week as tolerated. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 9's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 9 as ordered by the physician on 4/8, 4/9, 4/12, and 4/17. C. During a review of Resident 10's AR (AR 10), AR 10 indicated the facility initially admitted Resident 10 on 11/7/2020 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease affecting the right dominant side. During a review of Resident 10's H&P (H&P 10), dated 6/29/2023, H&P 10 indicated Resident 10 had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 4 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 - Some During a review of Resident 10's care plan (CP 10) regarding Resident 10's risk for falls related to a balance problem (initiated on 11/15/2018), CP 10 indicated the following interventions were initiated on 1/30/2024: 1) RNA Program PROM exercises to BLEs and RUE daily fivetimes a week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a review of Resident 10's MDS (MDS 10), dated 2/2/2024, MDS 10 indicated Resident 10 had no impairment in cognition. MDS 10 indicated Resident 10 was dependent on staff with toileting hygiene, showering/bathing, and mobility. During a review of Resident 10's OSR (OSR 10) for 4/2024, OSR 10 indicated the following active physician's orders: 1) Order Date: 3/1/2024 - RNA Program: RNA for right resting hand splint (device applied to support the extremity in the best position while resting daily 4-6 hours as tolerated with skin checks. Release every two hours for skin check every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. 2) Order Date: 3/1/2024 - RNA Program: PROM exercises to both lower extremities and right upper extremity daily five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 10's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 10 as ordered by the physician on 4/9, 4/15, 4/16, 4/19, 4/22, and 4/23. D. During a review of Resident 11's AR (AR 11), AR 11 indicated the facility initially admitted Resident 11 on 8/11/2023 with multiple diagnoses including history of falling and displaced bimalleolar fracture (broken ankle) of right lower leg. During a review of Resident 11's care plan (CP 11) regarding ADL self-care performance deficit (initiated on 8/22/2023), CP 11 indicated the following interventions were initiated on 10/24/2023: 1) RNA Program: PROM exercises to left and right lower extremities five times per week as tolerated. During a review of Resident 11's H&P (H&P 11), dated 1/3/2024, H&P 11 indicated Resident 11 had fluctuating capacity to understand and make decisions. During a review of Resident 11's MDS (MDS 11), dated 1/16/2024, MDS 11 indicated Resident 11 had severe impaired cognitive skills for daily decision-making. MDS 11 indicated Resident 11 was dependent on staff for all self-care activities and mobility. During a review of Resident 11's OSR (OSR 11) for 4/2024, OSR 11 indicated the following active physician's orders: 1) Order Date: 2/15/2024 - RNA Program: PROM exercises to left and right lower extremities five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 5 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 90 days. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 11's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 11 as ordered by the physician on 4/9, 4/17, and 4/19. Residents Affected - Some E. During a review of Resident 13's AR (AR 13), AR 13 indicated the facility initially admitted Resident 13 on 3/20/2024 with multiple diagnoses including right femoral neck fracture (broken hip), gait (manner of walking) and mobility abnormalities, general muscle weakness, liver cirrhosis (severe scarring of the liver), and heart failure. During a review of Resident 13's H&P (H&P 13), dated 3/21/2024, H&P 13 indicated Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's care plan (CP 13) regarding ADL self-care performance deficit (initiated on 3/21/2024), CP 13 indicated the following interventions were initiated on 4/15/2024: 1) RNA Program: AROM exercises to left and right lower extremities five times a week as tolerated. During a review of Resident 13's MDS (MDS 13), dated 3/27/2024, MDS 13 indicated Resident 13 had no impairment in cognition. MDS 13 indicated Resident 13 had impairment in both lower extremities. MDS 13 indicated Resident 13 was dependent on staff for showering/bathing and transfers, required substantial/maximal assistance with toileting hygiene and lower body dressing, and required partial/moderate assistance with upper body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 13's OSR (OSR 13) for 4/2024, OSR 13 indicated the following active physician's orders: 1) Order Date: 4/15/2024 - RNA Program: Active ROM (AROM, effort to move the body part without outside help or force) exercises to left and right lower extremities fivetimes per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 13's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 13 as ordered by the physician on 4/16, 4/17, and 4/19. F. During a review of Resident 14's AR (AR 14), AR 14 indicated the facility initially admitted Resident 14 on 3/27/2014 with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction and contractures (shortening of muscles, tendons, ligaments, and joints causing a deformity) of both ankles, left hand, and left elbow. During a review of Resident 14's MDS (MDS 14), dated 2/2/2024, MDS 14 indicated Resident 14 had no impairment in cognition. MDS 14 indicated Resident 14 was dependent on staff for most self-care activities and mobility. During a review of Resident 14's care plan (CP 14) regarding ADL self-care performance deficit (initiated on 8/13/2020), CP 14 indicated the following interventions were initiated on 3/5/2024: 1) RNA for left elbow splint everyday 4-6 hours as tolerated with skin check every 2-3 hours every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 6 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 day shift every Monday, Tuesday, Wednesday, Thursday, & Friday for 90 days. Level of Harm - Minimal harm or potential for actual harm 2) RNA Program: PROM exercises to LUE everyday five times a week or as tolerated. Residents Affected - Some During a review of Resident 14's H&P (H&P 14), dated 3/31/2024, H&P 14 indicated Resident 14 had joint pain and tenderness and increased weakness. H&P 14 indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's OSR (OSR 14) for 4/2024, OSR 14 indicated the following active physician's orders: 1) Order Date: 3/5/2024 - RNA for left elbow splint daily 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. 2) Order Date: 3/5/2024 - RNA Program: PROM exercises on left upper extremity five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 14's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 14 as ordered by the physician on 4/8, 4/9, 4/16, and 4/19. RNA 3 stated it was important to consistently provide RNA services to the residents as ordered by physician to prevent contractures or further decline in ROM and mobility, which could lead to increased risks of skin breakdown and pain. During a review of the facility's policy and procedure (P&P), titled Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated the following: 1. The comprehensive, person-centered care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. The comprehensive care plan must aid in preventing or reducing decline in the resident's functional status and/or functional levels. 3. Assessments of residents are ongoing and care plans must be revised as information about the residents and the residents' conditions change. 4. The Interdisciplinary Team (group of professionals from different disciplines) must review and update the care plan at least quarterly, when the desired outcome is not met, or when there has been a significant change in the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 7 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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. Based on interviews and record review, the facility failed to provide restorative nursing services (RNS, services provided to help residents maintain their function and joint mobility) as ordered by the physician for six of 15 sampled residents (Residents 7, 9, 10, 11, 13, & 14). A. For Resident 7, Restorative Nursing Aide (RNA) services were not provided for 5 days in 4/2024. B. For Resident 9, RNA services were not provided for 4 days in 4/2024. C. For Resident 10, RNA services were not provided for 6 days in 4/2024. D. For Resident 11, RNA services were not provided for 3 days in 4/2024. E. For Resident 13, RNA services were not provided for 3 days in 4/2024. F. For Resident 14, RNA services were not provided for 4 days in 4/2024. These failures had the potential to cause a decline/further decline in the residents' range of motion (ROM, measurement of the amount of movement around a specific joint or body part) with increased risks for pain and skin breakdown. (Cross Reference with F725 and F656) Findings: A. During a review of Resident 7's AR (AR 7), AR 7 indicated the facility initially admitted Resident 7 on 10/18/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interfere with daily activities) and morbid obesity (severely overweight). During a review of Resident 7's H&P (H&P 7), dated 10/19/2023, H&P 7 indicated Resident 7 had worsening confusion. H&P 7 indicated Resident 7 did not have the capacity to understand and make decisions. H&P 7 indicated Resident 7 required assistance with mobility and personal care. During a review of Resident 7's MDS (MDS 7, standardized resident assessment and care-planning tool), dated 1/19/2024, MDS 7 indicated Resident 7 had moderate impairment in cognition (ability to think, remember, and reason). MDS 7 indicated Resident 7 had an impairment in both lower extremities. MDS 7 indicated Resident 7 was dependent on staff for most self-care activities and transfers. During a review of Resident 7's Order Summary Report (OSR 7) for 4/2024, OSR 7 indicated the following active physician's order: 1) Order Date: 3/1/2024 - RNA Program: Apply multi-podus boot (device used to eliminate pressure or friction on the heel to prevent sores) to left and right feet 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. During an interview on 4/26/2024 at 10:22 AM, RNA 3 stated due to the shortage of Certified Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 8 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 Assistants (CNAs) on some days, the RNAs were tasked to do CNA duties and were assigned their own residents. RNA 3 stated there was no staff replacement to provide RNA services. RNA 3 stated when there was only 1 RNA assigned for the day, there was not enough time to provide RNA services, including ROM exercises, splinting, and ambulation, to more than 30 residents in the facility with RNA orders. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 7's Documentation Survey Report (DSR) for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 7 as ordered by the physician on 4/8, 4/9, 4/12, 4/16, and 4/19. B. During a review of Resident 9's AR (AR 9), AR 9 indicated the facility initially admitted Resident 9 on 3/17/2021 with multiple diagnoses including history of cerebral infarction (stroke, brain damage due to blocked blood supply to the brain), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and dementia. During a review of Resident 9's H&P (H&P 9), dated 8/13/2023, H&P 9 indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's MDS (MDS 9), dated 3/21/2024, MDS 9 indicated Resident 9 had severe impairment in cognition. MDS 9 indicated Resident 9 was dependent on staff for most self-care activities and mobility. During a review of the Resident 9's OSR (OSR 9) for 4/2024, OSR 9 indicated the following active physician's order: 1) Order Date: 3/1/2024 - RNA Program: Passive ROM (PROM, outside force exclusively causes movement of a joint) exercises to right upper extremity 5 times per week as tolerated every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 9's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 9 as ordered by the physician on 4/8, 4/9, 4/12, and 4/17. C. During a review of Resident 10's AR (AR 10), AR 10 indicated the facility initially admitted Resident 10 on 11/7/2020 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease affecting the right dominant side. During a review of Resident 10's H&P (H&P 10), dated 6/29/2023, H&P 10 indicated Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's MDS (MDS 10), dated 2/2/2024, MDS 10 indicated Resident 10 had no impairment in cognition. MDS 10 indicated Resident 10 was dependent on staff with toileting hygiene, showering/bathing, and mobility. During a review of Resident 10's OSR (OSR 10) for 4/2024, OSR 10 indicated the following active physician's orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 9 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 1) Order Date: 3/1/2024 - RNA Program: RNA for right resting hand splint (device applied to support the extremity in the best position while resting daily 4-6 hours as tolerated with skin checks. Release every 2 hours for skin check every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. 2) Order Date: 3/1/2024 - RNA Program: PROM exercises to both lower extremities and right upper extremity daily 5 times per week as tolerated every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 10's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 10 as ordered by the physician on 4/9, 4/15, 4/16, 4/19, 4/22, and 4/23. D. During a review of Resident 11's AR (AR 11), AR 11 indicated the facility recently readmitted Resident 11 on 1/3/2024 with multiple diagnoses including history of falling and displaced bimalleolar fracture (broken ankle) of right lower leg. During a review of Resident 11's H&P (H&P 11), dated 1/3/2024, H&P 11 indicated Resident 11 had fluctuating capacity to understand and make decisions. During a review of Resident 11's MDS (MDS 11), dated 1/16/2024, MDS 11 indicated Resident 11 had severe impaired cognitive skills for daily decision-making. MDS 11 indicated Resident 11 was dependent on staff for all self-care activities and mobility. During a review of Resident 11's OSR (OSR 11) for 4/2024, OSR 11 indicated the following active physician's orders: 1) Order Date: 2/15/2024 - RNA Program: PROM exercises to left and right lower extremities 5 times per week as tolerated every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 11's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 11 as ordered by the physician on 4/9, 4/17, and 4/19. E. During a review of Resident 13's AR (AR 13), AR 13 indicated the facility initially admitted Resident 13 on 3/20/2024 with multiple diagnoses including right femoral neck fracture (broken hip), gait (manner of walking) and mobility abnormalities, general muscle weakness, liver cirrhosis (severe scarring of the liver), and heart failure. During a review of Resident 13's H&P (H&P 13), dated 3/21/2024, H&P 13 indicated Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's MDS (MDS 13), dated 3/27/2024, MDS 13 indicated Resident 13 had no impairment in cognition. MDS 13 indicated Resident 13 had impairment in both lower extremities. MDS 13 indicated Resident 13 was dependent on staff for showering/bathing and transfers, required substantial/maximal assistance with toileting hygiene and lower body dressing, and required partial/moderate assistance with upper body dressing, putting on/taking off footwear, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 10 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 13's OSR (OSR 13) for 4/2024, OSR 13 indicated the following active physician's orders: 1) Order Date: 4/15/2024 - RNA Program: Active ROM (AROM, effort to move the body part without outside help or force) exercises to left and right lower extremities 5 times per week as tolerated every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 13's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 13 as ordered by the physician on 4/16, 4/17, and 4/19. F. During a review of Resident 14's AR (AR 14), AR 14 indicated the facility initially admitted Resident 14 on 3/27/2014 with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction and contractures (shortening of muscles, tendons, ligaments, and joints causing a deformity) of both ankles, left hand, and left elbow. During a review of Resident 14's MDS (MDS 14), dated 2/2/2024, MDS 14 indicated Resident 14 had no impairment in cognition. MDS 14 indicated Resident 14 was dependent on staff for most self-care activities and mobility. During a review of Resident 14's H&P (H&P 14), dated 3/31/2024, H&P 14 indicated Resident 14 had joint pain and tenderness and increased weakness. H&P 14 indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's OSR (OSR 14) for 4/2024, OSR 14 indicated the following active physician's orders: 1) Order Date: 3/5/2024 - RNA for left elbow splint daily 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. 2) Order Date: 3/5/2024 - RNA Program: PROM exercises on left upper extremity 5 times per week as tolerated every day shift every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 14's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 14 as ordered by the physician on 4/8, 4/9, 4/16, and 4/19. RNA 3 stated it was important to consistently provide RNA services to the residents as ordered by physician to prevent contractures or further decline in ROM and mobility, which could lead to increased risks of skin breakdown and pain. During an interview on 4/30/2024 at 3:44 PM, the Director of Nursing (DON) stated RNA services must be provided consistently to the residents as ordered by the physician to prevent the further decline of the residents' ROM and mobility. The DON stated it was not possible to provide RNA services consistently as ordered by the physician if the RNAs are reassigned to perform CNA duties for the shift. During a review of the facility's policy and procedure (P&P), titled Restorative Nursing Services, dated 2001, the P&P indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 11 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 1. Residents must receive restorative nursing care as needed to help promote optimal safety and independence. 2. Restorative goals and objectives are individualized and resident-centered and must be outlined in the resident's plan of care. Residents Affected - Some 3. Restorative goals might include, but not limited to supporting and assisting the resident in a. Adjusting or adapting to changing abilities, b. Developing, maintaining or strengthening his/her physiological and psychological resources, c. Maintaining his/her dignity, independence and self-esteem, and d. Participating in the development and implementation of his/her plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 12 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interviews and record review, the facility failed to ensure sufficient nursing staff, including certified nursing assistants (CNAs, staff to provide care to residents and assist with mobility ) and restorative nursing aides (RNAs, staff to help improve and/or maintain residents' function and joint mobility), were assigned to provide care for seven of 15 sampled residents (Residents 1, 7, 9, 10, 11, 13, & 14) in accordance with the residents' needs and preferences, physician's orders, and/or residents' care plans by failing to: A. Accommodate Resident 1's needs and preferences regarding the call light response time, getting out of bed (OOB), and incontinence brief changes. B. Provide Restorative Nursing Aide (RNA) services to Resident 7 as ordered by the physician in 4/2024. C. Provide RNA services to Resident 9 as ordered by the physician in 4/2024. D. Provide RNA services to Resident 10 as ordered by the physician in 4/2024. E. Provide RNA services to Resident 11 as ordered by the physician in 4/2024. F. Provide RNA services to Resident 13 as ordered by the physician in 4/2024. G. Provide RNA services to Resident 14 as ordered by the physician in 4/2024. These failures had the potential to result in a decline in the residents' physical and psychosocial well-being due to reduced quality of care related to staff burnout and/or inconsistent RNA services provided. (Cross Reference with F558 and F688) Findings: A. During a review of Resident 1's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 1 on 9/29/2023 with multiple diagnoses including a history of stroke (brain damage due to blocked blood supply to the brain), left shoulder osteoarthritis (degenerative joint disease), epilepsy (brain disorder causing seizures), abnormalities of gait (manner of walking) and mobility, and lack of coordination. During a review of Resident 1's Initial History and Physical (H&P 1), dated 9/29/2023, H&P 1 indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 4/5/2024, MDS 1 indicated Resident 1 did not have an impairment in cognition (ability to think, remember, and reason). MDS 1 indicated Resident 1 had an impairment on one side of Resident 1's upper extremities and an impairment on both sides of Resident 1's lower extremities. MDS 1 indicated Resident 1 was frequently incontinent of urine (loss of bladder control). MDS 1 indicated Resident 1 was dependent on staff for most self-care activities and required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 13 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 0725 maximal/substantial assistance with mobility and transfers. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's care plan (CP) on ADL self-care performance deficit, dated 10/11/2023, the CP indicated Resident 1 was totally dependent on staff for personal and toileting hygiene and lower body dressing. The CP indicated Resident 1 required substantial/maximal assistance with lying to sitting on one side of the bed. The CP indicated the intervention to Encourage the resident to use [the] bell to call for assistance. Residents Affected - Some During an interview on 4/26/2024 at 11:04 AM, Resident 1 stated he wanted to get OOB earlier that day, but he had to wait until 10 AM because there was no staff to assist him. Resident 1 stated he has verbalized his concerns to the staff before. Resident 1 stated, They don't have enough staff. CNAs are overworked. During an interview on 4/26/2024 at 11:49 AM, CNA 4 stated due to the staffing shortage, CNA 4 was able to change the residents' incontinence brief twice per shift-one in the morning and one in the afternoon. CNA 4 stated changing and turning/repositioning of residents must be done every two hours and as needed for all residents. CNA 4 stated when answering call lights, some residents would get mad because of waiting for a long time because CNA 4 was busy with providing care to another resident. CNA 4 stated Director of Staff Development 1 (DSD 1) would get mad at the staff or give the staff a hard time when the staff member would bring up the staffing shortage problem. CNA 4 stated DSD 1 did not call the Registry for assistance with staffing when short-staffed. CNA 4 stated DSD 1 would not answer the staff phone calls to request for assistance with staffing when short-staffed. CNA 4 stated it was difficult to provide good care when assigned with 11 or 12 residents during the 7 AM - 3 PM shift. During an interview on 4/26/2024 at 12:49 PM, CNA 5 stated in 3/2024, each 7 AM - 3 PM shift CNA was assigned 14 residents each. CNA 5 stated when staff verbalized to DSD 1 that It was too much for them, DSD 1 stated, They have to do it. CNA 5 stated each CNA was regularly getting assigned 12, 13, or 14 residents. CNA 5 stated DSD 1 would not call the other regular staff to inquire if available to help. CNA 5 stated Registry staff was requested to come in 4/2024 but the facility was still short-staffed, because the Registry staff would not show up. During an interview on 4/26/2024 at 1:09 PM, CNA 6 stated due to the staffing shortage, CNA 6 could not answer the call lights in a timely manner. CNA 6 stated CNA 6 would change the residents' incontinence brief twice per shift-in the morning and after lunch. CNA 6 stated CNA 6 could go not back to the resident room to change and reposition/turn the resident at least every two hours as required. CNA 6 stated some staff are not able to take their breaks due to the busy workload. During an interview on 4/26/2024 at 1:28 PM, CNA 7 stated due to the staffing shortage, call lights were not answered because CNAs were busy providing care to the other residents. CNA 7 stated CNA 7 would change residents' incontinence brief twice per shift and turning/repositioning was done only for the people who really needed it. CNA 7 stated all residents must be changed and turned/repositioned at least every two hours and as needed. CNA 7 stated when CNA 7 talked to DSD 1 regarding the staffing shortage, DSD 1 did not offer solutions and only stated, You have to do your job. During an interview on 4/26/2024 at 3:30 PM, Licensed Vocational Nurse 1 (LVN 1) stated the facility has staffing shortage for CNAs. LVN 1 stated when LVN 1 called DSD 1 for assistance with staffing, DSD 1 did not answer the phone call most of the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 14 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a telephone interview on 4/29/2024 at 12:34 PM, Registered Nurse 1 (RN 1) stated there was a staffing shortage for both CNAs and LVNs in the facility. RN 1 stated a lot of staff were quitting or calling off a lot, because they get overwhelmed with the workload. RN 1 stated RNAs were being reassigned to help on the floor with CNA duties. During a telephone interview on 4/29/2024 at 1:06 PM, DSD 1 stated when DSD 1 first started, the facility's Direct Care Service Hours Per Patient Day (DHPPD, system developed to provide the facilities a tool to assess the value nursing staff provides around resident safety and care quality) was very high and the goal was to stay in compliance and not go over the labor expense. DSD 1 stated the company did not want us to use Registry. During an interview on 4/30/2024 at 2:07 PM, DSD 2 stated the facility did not pressure DSD 2 not to go over the numbers (DHPPD). DSD 2 stated the staff assignment was based on the acuity of residents. DSD 2 stated if RNAs were reassigned to do CNA duties, the on-call RNA was called or the RNA was asked to stay over to provide RNA services as ordered by the physician. DSD 2 stated it was the DSD's responsibility to ensure sufficient staffing. DSD 2 stated if short-staffed, residents could develop skin breakdown, have a decline in ROM or mobility, and fall and sustain injuries. B. During a review of Resident 7's AR (AR 7), AR 7 indicated the facility initially admitted Resident 7 on 10/18/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interfere with daily activities) and morbid obesity (severely overweight). During a review of Resident 7's H&P (H&P 7), dated 10/19/2023, H&P 7 indicated Resident 7 had worsening confusion. H&P 7 indicated Resident 7 did not have the capacity to understand and make decisions. H&P 7 indicated Resident 7 required assistance with mobility and personal care. During a review of Resident 7's MDS (MDS 7), dated 1/19/2024, MDS 7 indicated Resident 7 had moderate impairment in cognition. MDS 7 indicated Resident 7 had an impairment in both lower extremities. MDS 7 indicated Resident 7 was dependent on staff for most self-care activities and transfers. During a review of Resident 7's Order Summary Report (OSR 7) for 4/2024, OSR 7 indicated the following active physician's order: 1) Order Date: 3/1/2024 - RNA Program: Apply multi-podus boot (device used to eliminate pressure or friction on the heel to prevent sores) to left and right feet 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During an interview on 4/26/2024 at 10:22 AM, RNA 3 stated due to the shortage of CNAs on some days, the RNAs were tasked to do CNA duties and were assigned their own residents. RNA 3 stated there was no staff replacement to provide RNA services. RNA 3 stated when there was only 1 RNA assigned for the day, there was not enough time to provide RNA services, including ROM exercises, splinting (application of a device called a splint to support the extremity in the best position while resting), and ambulation, to more than 30 residents in the facility with RNA orders. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 7's Documentation Survey Report (DSR) for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 7 as ordered by the physician on 4/8, 4/9, 4/12, 4/16, and 4/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 15 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some C. During a review of Resident 9's AR (AR 9), AR 9 indicated the facility initially admitted Resident 9 on 3/17/2021 with multiple diagnoses including history of cerebral infarction (stroke, brain damage due to blocked blood supply to the brain), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and dementia. During a review of Resident 9's H&P (H&P 9), dated 8/13/2023, H&P 9 indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's MDS (MDS 9), dated 3/21/2024, MDS 9 indicated Resident 9 had severe impairment in cognition. MDS 9 indicated Resident 9 was dependent on staff for most self-care activities and mobility. During a review of the Resident 9's OSR (OSR 9) for 4/2024, OSR 9 indicated the following active physician's order: 1) Order Date: 3/1/2024 - RNA Program: Passive ROM (PROM, outside force exclusively causes movement of a joint) exercises to right upper extremity five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 9's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 9 as ordered by the physician on 4/8, 4/9, 4/12, and 4/17. D. During a review of Resident 10's AR (AR 10), AR 10 indicated the facility initially admitted Resident 10 on 11/7/2020 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease affecting the right dominant side. During a review of Resident 10's H&P (H&P 10), dated 6/29/2023, H&P 10 indicated Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's MDS (MDS 10), dated 2/2/2024, MDS 10 indicated Resident 10 had no impairment in cognition. MDS 10 indicated Resident 10 was dependent on staff with toileting hygiene, showering/bathing, and mobility. During a review of Resident 10's OSR (OSR 10) for 4/2024, OSR 10 indicated the following active physician's orders: 1) Order Date: 3/1/2024 - RNA Program: RNA for right resting hand splint daily 4-6 hours as tolerated with skin checks. Release every 2 hours for skin check every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. 2) Order Date: 3/1/2024 - RNA Program: PROM exercises to both lower extremities and right upper extremity daily five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 10's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 10 as ordered by the physician on 4/9, 4/15, 4/16, 4/19, 4/22, and 4/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 16 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some E. During a review of Resident 11's AR (AR 11), AR 11 indicated the facility recently readmitted Resident 11 on 1/3/2024 with multiple diagnoses including history of falling and displaced bimalleolar fracture (broken ankle) of right lower leg. During a review of Resident 11's H&P (H&P 11), dated 1/3/2024, H&P 11 indicated Resident 11 had fluctuating capacity to understand and make decisions. During a review of Resident 11's MDS (MDS 11), dated 1/16/2024, MDS 11 indicated Resident 11 had severe impaired cognitive skills for daily decision-making. MDS 11 indicated Resident 11 was dependent on staff for all self-care activities and mobility. During a review of Resident 11's OSR (OSR 11) for 4/2024, OSR 11 indicated the following active physician's orders: 1) Order Date: 2/15/2024 - RNA Program: PROM exercises to left and right lower extremities five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 11's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 11 as ordered by the physician on 4/9, 4/17, and 4/19. F. During a review of Resident 13's AR (AR 13), AR 13 indicated the facility initially admitted Resident 13 on 3/20/2024 with multiple diagnoses including right femoral neck fracture (broken hip), gait (manner of walking) and mobility abnormalities, general muscle weakness, liver cirrhosis (severe scarring of the liver), and heart failure. During a review of Resident 13's H&P (H&P 13), dated 3/21/2024, H&P 13 indicated Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's MDS (MDS 13), dated 3/27/2024, MDS 13 indicated Resident 13 had no impairment in cognition. MDS 13 indicated Resident 13 had impairment in both lower extremities. MDS 13 indicated Resident 13 was dependent on staff for showering/bathing and transfers, required substantial/maximal assistance with toileting hygiene and lower body dressing, and required partial/moderate assistance with upper body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 13's OSR (OSR 13) for 4/2024, OSR 13 indicated the following active physician's orders: 1) Order Date: 4/15/2024 - RNA Program: Active ROM (AROM, effort to move the body part without outside help or force) exercises to left and right lower extremities five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 13's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 13 as ordered by the physician on 4/16, 4/17, and 4/19. G. During a review of Resident 14's AR (AR 14), AR 14 indicated the facility initially admitted Resident 14 on 3/27/2014 with multiple diagnoses including hemiplegia and hemiparesis following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 17 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cerebral infarction and contractures (shortening of muscles, tendons, ligaments, and joints causing a deformity) of both ankles, left hand, and left elbow. During a review of Resident 14's MDS (MDS 14), dated 2/2/2024, MDS 14 indicated Resident 14 had no impairment in cognition. MDS 14 indicated Resident 14 was dependent on staff for most self-care activities and mobility. During a review of Resident 14's H&P (H&P 14), dated 3/31/2024, H&P 14 indicated Resident 14 had joint pain and tenderness and increased weakness. H&P 14 indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's OSR (OSR 14) for 4/2024, OSR 14 indicated the following active physician's orders: 1) Order Date: 3/5/2024 - RNA for left elbow splint daily 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. 2) Order Date: 3/5/2024 - RNA Program: PROM exercises on left upper extremity five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 14's DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 14 as ordered by the physician on 4/8, 4/9, 4/16, and 4/19. During an interview on 4/30/2024 at 3:44 PM, the Director of Nursing (DON) stated RNA services must be provided consistently to the residents as ordered by the physician to prevent the further decline of the residents' ROM and mobility. The DON stated it was not possible to provide RNA services consistently as ordered by the physician if the RNAs are reassigned to perform CNA duties for the shift. The DON stated DSD 1 did not schedule enough CNAs in advance. The DON stated the licensed nurses would call DSD 1 to request for staffing assistance, but DSD 1 would not respond. During a review of the facility's policy and procedure (P&P), titled Staffing, dated 2001, the P&P indicated the following: 1. The facility must provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 2. Staffing numbers and the skill requirements of direct care staff must be determined by the needs of the residents based on each resident's plan of care. 3. Licensed nurses and certified nursing assistants must be available 24 hours a day to provide direct resident care services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 18 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to verify the competencies and skills sets of the nursing staff to ensure appropriate nursing care and services were provided to the residents by failing to: A. Ensure three of nine sampled Certified Nursing Assistants (CNAs) had an active CNA certification. B. Ensure Director of Staff Development 1 (DSD 1) conducted a Skills Competency test for two of three sampled newly hired CNAs prior to working independently as a CNA. C. Ensure DSD 1 identified the learning needs of four of 27 sampled nursing staff and determine there was no documented evidence on file of a current Cardiopulmonary Resuscitation training (CPR, basic training on life-saving actions during cardiac emergencies) or Basic Life Support training (BLS, CPR training with additional life-saving techniques for those experiencing respiratory distress or an obstructed airway). D. Ensure DSD 1 addressed the staffing shortage brought up by the nursing staff that affected the quality of care provided to the residents. These failures had the potential for all residents to receive incorrect and/or delayed treatments and services related to lack of staff competence. (Cross Reference with F725) Findings: A. During an interview on [DATE] at 1:09 PM, CNA 6 stated there were CNAs working in the facility with expired CNA certifications. During a telephone interview on [DATE] at 1:06 PM, DSD 1 stated the DSD must verify an active CNA certification upon hiring a new CNA. During an interview on [DATE] at 1:52 PM, CNA 8 stated CNA 8's CNA certification expired on [DATE], so CNA 8 was not currently assigned any resident care tasks. CNA 8 stated DSD 1 had errors in filling out the CNA certification renewal paperwork and providing the required in-services, which delayed the CNA certification renewal process. During an interview on [DATE] at 1:51 PM, DSD 2 stated DSD 2 kept a log of CNA certifications and assisted with the CNA certification renewals within 2-3 months prior to the CNA certifications' expiration date. DSD 2 stated this was to ensure all staff provide quality care to all the residents at all times. DSD 2 stated when CNA 8's CNA certification expired, CNA 8 was not allowed to perform CNA duties, but CNA 8 continued to work in the facility. DSD 2 stated the facility required a staff for non-resident care-related duties, such as escorts for residents' medical appointments, a staff to clean and organize the closets and label some personal items. During a concurrent interview and record review on [DATE] at 3:04 PM with the Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 19 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 - Some (DON), the employee files and timecards for 4/2024 of sampled nursing staff were reviewed. The DON stated CNA 10 and CNA 11 had no active CNA certification when CNA 10 and CNA 11 performed CNA duties in the facility in 4/2024. During a review of the facility's policy and procedure (P&P), titled Staffing, dated 2001, the P&P indicated the facility must provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. During a review of the facility's DSD Job Description (JD 1, undated), JD 1 indicated the DSD must maintain employee files and health records of nursing staff. During a review of the facility's CNA Job Description (JD 2, undated), JD 2 indicated the CNAs were required to complete a certification program for Nursing Assistants and to maintain a current CNA certification. B. During a telephone interview on [DATE] at 1:06 PM, DSD 1 stated performance evaluations and Skills Competency tests of all staff must be conducted upon hire, annually, and as needed if there were any concerns with the staff competencies. During an interview on [DATE] at 1:51 PM, DSD 2 stated CNA Skills Competency tests must be conducted within 7 days upon hire and annually thereafter to determine the CNA readiness to perform CNA duties. During a concurrent interview and record review on [DATE] at 3:04 PM with the Director of Nursing (DON), the employee files of sampled nursing staff were reviewed. The DON stated there was no documented evidence that DSD 1 conducted a CNA Skills Competency test for CNA 10 and CNA 11. The DON stated CNA 11's Pre-Employment Reference Verification Checklist (reference check to verify previous work history) was questionable. During a review of the facility's DSD Job Description (JD 1, undated), JD 1 indicated the following: 1. The DSD must assess the learning needs of personnel in order to meet the needs of the resident, organization, and employee. 2. The DSD must direct and deliver orientation programs for all personnel in accordance with established policies and procedures including new hire paperwork. 3. The DSD must monitor and supervise continuity between classroom and clinical application by skills checks and individual training. During a review of the facility's Job Description (JD 2, undated) for the Certified Nursing Assistant (CNA), JD 2 indicated CNAs must be knowledgeable of nursing/medical practices and procedures, and/or terminology, laws, regulations, and the guidelines that pertain to long-term care. C. During a concurrent interview and record review on [DATE] at 1:22 PM with DSD 2, the CPR/BLS certifications of the sampled staff were reviewed. DSD 2 stated there was no documented evidence of a current CPR/BLS certification for CNA 11, CNA 12, CNA 13, and CNA 15, who worked in 4/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 20 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 - Some During a telephone interview on [DATE] at 1:06 PM, DSD 1 stated DSD must verify a current CPR/BLS certification upon hiring a new CNA. DSD 1 stated the goal was to keep a current CPR/BLS certification for all staff. During an interview on [DATE] at 1:51 PM, DSD 2 stated CPR/BLS certifications must be kept current and if CNAs would need to renew their CPR/BLS certifications, the DSD could organize the BLS/CPR class and have an instructor come to the facility to conduct the CPR/BLS training. During a review of the facility's DSD Job Description (JD 1, undated), JD 1 indicated the DSD must assess the learning needs of personnel in order to meet the needs of the resident, organization, and employee. During a review of the facility's CNA Job Description (JD 2, undated), JD 2 indicated in terms of CNA knowledge, skills, abilities, and qualifications, a current valid CPR certification was strongly preferred. D. During an interview on [DATE] at 11:49 AM, CNA 4 stated due to the staffing shortage, CNA 4 stated DSD 1 would get mad at the staff or give the staff a hard time when the staff member would bring up the staffing shortage problem. CNA 4 stated DSD 1 did not call the Registry (contracted company to provide emergency staffing) for assistance with staffing when the facility was short-staffed. CNA 4 stated DSD 1 would not answer the staff phone calls to request for assistance with staffing when short-staffed. CNA 4 stated it was difficult to provide good care when assigned with 11 or 12 residents during the 7 AM - 3 PM shift. During an interview on [DATE] at 12:49 PM, CNA 5 stated in 3/2024, each 7 AM - 3 PM shift CNA was assigned 14 residents each. CNA 5 stated when staff verbalized to DSD 1 that It was too much for them, DSD 1 stated, They (CNAs) have to do it. CNA 5 stated each CNA was regularly getting assigned 12, 13, or 14 residents. CNA 5 stated DSD 1 would not call the other regular staff to inquire if available to help. CNA 5 stated Registry staff was requested to come in 4/2024 but the facility was still short-staffed, because the Registry staff would not show up. During an interview on [DATE] at 1:09 PM, CNA 6 stated some staff are not able to take their breaks due to the busy workload. During an interview on [DATE] at 1:28 PM, CNA 7 stated due to the staffing shortage, call lights were not answered because CNAs were busy providing care to the other residents. CNA 7 stated CNA 7 would change residents' incontinence brief twice per shift and turning/repositioning was done only for the people who really needed it. CNA 7 stated all residents must be changed and turned/repositioned at least every 2 hours and as needed. CNA 7 stated when CNA 7 talked to DSD 1 regarding the staffing shortage, DSD 1 did not offer solutions and only stated, You have to do your job. During an interview on [DATE] at 3:30 PM, Licensed Vocational Nurse 1 (LVN 1) stated the facility has staffing shortage for CNAs. LVN 1 stated when LVN 1 called DSD 1 for assistance with staffing, DSD 1 did not answer the phone calls most of the time. During a telephone interview on [DATE] at 12:34 PM, Registered Nurse 1 (RN 1) stated there was a staffing shortage for both CNAs and LVNs in the facility. RN 1 stated a lot of staff were quitting or calling off a lot, because they got overwhelmed with the workload. RN 1 stated RNAs were being reassigned to help on the floor with CNA duties. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 21 of 22 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 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 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 During a telephone interview on [DATE] at 1:06 PM, DSD 1 stated when DSD 1 first started, the facility's Direct Care Service Hours Per Patient Day (DHPPD, system developed to provide the facilities a tool to assess the value nursing staff provides around resident safety and care quality) was very high and the goal was to stay in compliance and not go over the labor expense. DSD 1 stated the company did not want us to use Registry. Residents Affected - Some During an interview on [DATE] at 2:07 PM, DSD 2 stated the facility did not pressure DSD 2 not to go over the numbers (DHPPD). DSD 2 stated the staff assignment was based on the acuity of residents. DSD 2 stated if RNAs were reassigned to do CNA duties, the on-call RNA was called or the RNA was asked to stay over to provide RNA services as ordered by the physician. DSD 2 stated it was the DSD's responsibility to ensure sufficient staffing. DSD 2 stated if short-staffed, residents could develop skin breakdown, have a decline in range of motion or mobility, and fall and sustain injuries. During a review of the facility's policy and procedure (P&P), titled Staffing, dated 2001, the P&P indicated the following: 1. The facility must provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 2. Staffing numbers and the skill requirements of direct care staff must be determined by the needs of the residents based on each resident's plan of care. During a review of the facility's DSD Job Description (JD 1, undated), JD 1 indicated the following: 1. The DSD must monitor the activities of nursing personnel to ensure quality care complies with the state, federal, and corporate standards. 2. The DSD must serve in mentoring capacity to CNAs and RNAs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 22 of 22