Health inspection·June 16, 2024

F 0578 glucose/sugar in the blood and urine) with hyperglycemia (high blood sugar). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 9's History and Physical (H&P), dated 12/6/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 9's Physician Orders for Life-Sustaining Treatment (POLST) dated 12/20/2022, the POLST indicated Resident 9 did not have an AD. During a review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/22/2024, the MDS indicated Resident 9 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 9 was dependent with toileting hygiene, shower, lower body dressing and putting on or taking off footwear. During a review of Resident 9's AD Acknowledgement form, dated 6/14/2024, the AD Acknowledgement form was not filled out completely. The two boxes to determine if the resident had executed an AD or not were left unchecked. During an interview and concurrent record review of Resident 9's MR on 6/15/2024 at 9:59 am, with the Social Service Director (SSD), the SSD stated Resident 9's AD Acknowledgement Form needed to be filled out completely. The SSD stated it was Resident 9's right to formulate AD for the facility to provide care and treatment to follow Resident 9's wishes. During an interview on 6/15/2024 at 11:41 am, with the facility's Director of Nursing (DON), the DON stated, Resident 9's Acknowledgement Form needed to be filled out completely by SSD. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised 9/2022, the P&P indicated prior to or upon admission of a resident, the social service director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. If the resident or the resident's representative has executed one or more advance directives, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 2 of 15 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 06/16/2024 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 19) who had a diagnoses of Cystitis (inflammation of the bladder) and on Bactrim ([sulfamethoxazole/trimethoprim] medication that treat infection) as indicated in the facility's policy and procedure, titled Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 19 to not receive necessary care, treatment and/or services. Findings: During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted Resident 19 on 5/8/2023 with diagnoses that included chronic cystitis (inflammation of the bladder) without hematuria (blood in the urine) and overactive bladder (sudden urges to urinate that may be hard to control). During a review of Resident 19's History and Physical (H&P), dated 5/9/2023, the H&P indicated Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's Physician Orders (PO), dated 10/17/2023, the PO indicated for licensed staff to administer Bactrim Oral Tablet one tablet 400-80 milligrams (mg, unit of measurement) by mouth daily at bedtime for chronic cystitis without hematuria; to continue indefinitely per Urology (medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the kidneys, ureters, bladder, and urethra). During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/14/2024, the MDS indicated, Resident 19 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 19 was dependent to staff with toileting, shower, lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 6/15/2024 at 11:26 am with Registered Nurse Supervisor 2 (RN Sup 2), Resident 19's medical record was reviewed. The RN Sup 2 stated there was no clinical documentation that a CP was developed for Resident 19 to address the resident's Cystitis and CP to address the use of antibiotic Bactrim. The RN Sup 2 stated CP for Resident 19 should have been initiated to provide guidance to staff on how to provide treatment to Resident 19 with Cystitis and was on Bactrim. During a concurrent interview and record review on 6/15/2024 at 11:38 am with the facility's Director of Nursing (DON), the DON stated CP should have been developed to ensure Resident 19 received necessary care and treatment to address Resident 19's specific needs. During a review of the facility's P&P titled, Care Plans - Comprehensive Person-Centered, revised 3/2022, the P&P indicated the comprehensive, person-centered care plan needed to be developed within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 3 of 15 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 06/16/2024 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 seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 4 of 15 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 06/16/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform a smoking assessment (an assessment that helps to determine how can help a patient who smokes) upon admission for one of two sampled residents (Resident 100). This failure had the potential to result in unsafe smoking behaviors causing harm to residents. Findings: During a review of Resident 100's admission Record (AR), the AR indicated Resident 100 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (sudden condition when the lungs cannot get enough oxygen into the blood) and hypertension (increased blood pressure). During an observation on 6/15/2024 at 3:48 pm, in the facility's designated smoking area, Resident 100 was observed smoking together with one of Resident 100's visitors. During a concurrent interview, Resident 100 stated Resident 100 was newly admitted to the facility and had a smoking history of more than 40 years. During a review of Resident 100's History and Physical (H&P) dated 6/15/2024, the H&P indicated Resident 100 had the capacity to understand and make decisions. During a review of Resident 100's Medical Record (MR), there was no smoking assessment performed for Resident 100. During an interview and concurrent record review on 6/15/2024 at 4:01 pm with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated, Resident 100 was admitted on [DATE] and the facility did not know Resident 100 was a smoker. LVN 5 stated there was no smoking assessment performed upon admission of Resident 100. LVN 5 stated, upon admission, the admitting staff needed to ask the resident's smoking history and smoking assessment should be performed for residents who smoke. LVN 5 stated, the purpose of smoking assessment was to evaluate safe resident smoking practices. During a review of the facility's Policy and Procedure (P&P) titled Smoking Policy-Residents, revised 10/2023, the P&P indicated prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Resident smoking status is evaluated upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 5 of 15 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 06/16/2024 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 43' AR, the AR indicated Resident 43 was admitted to the facility on [DATE], with diagnoses that included acute osteomyelitis (bone infection) of the right ankle and foot and anemia (a condition in which the body does not have enough healthy red blood cells). Residents Affected - Some During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 had clear speech, had the ability to understand others and made self understood. The MDS indicated Resident 43 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for personal hygiene and chair/bed-to-chair transfers. During an observation on 6/14/2024 at 6:16 pm, Resident 43 was lying in bed. Resident 43 had a PICC line on the right upper arm. Resident 43's PICC line's insertion site was covered with dressing and the dressing was not labeled with date of insertion or change. During a concurrent interview with the Infection Preventionist Nurse (IPN- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment), the IPN stated Resident 43's PICC dressing should be labeled with the date the dressing was changed so that the staff knew when to change the dressing. The IPN stated, PICC line dressing needed to be changed every seven days to prevent accumulation of bacteria causing infection. During a review of the facility's P&P titled Guidelines for Preventing Intravenous Catheter-Related Infections, revised 8/2014,the P&P indicated change transparent, semi permeable membrane (TSM) dressing on central venous access devices (CVD), catheters inserted into peripheral veins or central veins in the chest, neck or groin, which travel through the venous system every 5-7 days or as needed (PRN) if damp, loosened, or visibly soiled. Based on observation, interview, and record review, the facility failed to provide appropriate care and services for peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) line and peripheral intravenous (PIV, a short , flexible plastic tube that is inserted into a vein through the skin) line for three of three sampled residents (Residents 43, 46 and 200) by failing to : a. Ensure the PICC line port was covered with a cap and not left open and exposed to the air, when not in use in accordance with the facility's Policy and Procedure (P&P) on Guidelines for Preventing Intravenous Catheter-Related Infections. b. Label and date the PIV for Resident 200) in accordance with the facility's P&P titled Peripheral IV Dressing Changes. c. Label the PICC line dressing with date of insertion and/or change of dressing. These deficient practices had the potential to result in infection and complications and worsen the health condition for Residents 43, 46 and 200. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 6 of 15 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 06/16/2024 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. During a review of Resident 46's admission Records (AR), the AR indicated Resident 46 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening generalized infection of the body) and cellulitis (bacterial infection involving the inner layers of the skin) of the right lower limb. During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/27/2024, the MDS indicated Resident 46 had intact cognition (ability to understand) and required moderate assistance (helper does more than half the effort) with toileting, shower, and lower body dressing. During a review of Resident 46's Care Plan (CP), dated 5/21/2024, the CP indicated Resident 46 was on intravenous (IV) medications via (through) PICC line on the right upper arm. The CP had a goal for Resident 46 not to have any complications related to IV therapy. During an observation on 6/14/2024 at 6:26 pm inside Resident 46's room, Resident 46 had a PICC line with 2 ports. One of the PICC line ports was exposed and not covered with a cap. During an interview on 6/14/2024 at 6:44 pm with the Infection Preventionist Nurse (IPN), IPN stated all PICC line ports should be covered with a cap and should not be left open to the air when not in use to prevent infection. During an interview on 6/16/2024 at 9:58 am with the Director of Nursing (DON), the DON stated, all PICC line, central line and peripheral ports should be covered and capped at all times when not in use to prevent access of bacteria and dirt on the ports and cause infection to the residents. During a review of the facility's undated P&P titled, Guideline for Preventing Intravenous Catheter-Related Infections, the P&P indicated, Any time that dressing is not intact or end caps are missing, the catheter has potential for contamination. b. During a review of Resident 200's AR, the AR indicated Resident 200 was admitted to the facility on [DATE] with diagnoses that included cellulitis on right lower limb. During a review of Resident 200's Physicians Order (PO), dated 6/14/2024, the PO indicated for licensed staff to change the peripheral site dressing for Resident 200 every 72 hours and as needed. During a concurrent observation and interview on 6/14/2024 at 6:16 pm with Licensed Vocational Nurse 1 (LVN 1), Resident 200 was awake lying in bed with peripheral IV site on the left hand. The peripheral IV site was not dated when it was changed. LVN 1 stated Resident 200's IV site was not labeled with date to identify when it was inserted by the licensed nurse (in general). During a concurrent observation and interview on 6/14/2024 at 7:03 pm with Registered Nurse Supervisor 1 (RN Sup 1) Resident 200's peripheral IV site was inspected. The RN Sup 1 stated, Resident 200's peripheral IV site was not labeled with date when it was inserted. RN Sup 1 stated Resident 200's peripheral IV site needed to be labeled with date, time and with the licensed nurse's initial to determine when it was changed to prevent infection. During an interview on 6/15/2024 at 11:44 am with the facility's Director of Nursing (DON), the DON stated Resident 200's IV site needed to be labeled with date and licensed nurse's initial every 72 hours to know when it was changed to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 7 of 15 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 06/16/2024 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 0694 During a review of the facility's P&P titled, Peripheral IV Dressing Changes, dated 4/2016, the P&P indicated to label the IV dressing with date, time and initials. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 8 of 15 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 06/16/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 25's AR, the AR indicated Resident 25 was admitted to the facility on [DATE], with diagnoses that included hydrocephalus (abnormal buildup of cerebrospinal fluid [fluid found within the tissues surrounding the brain] in the ventricles [cavities] within the brain) and hypertension (increased blood pressure). Residents Affected - Some During a review of Resident 25's OSR dated 4/24/2024, the OSR indicated Resident 25 was prescribed Ipratropium-Albuterol (medicine used for breathing treatment) Inhalation orally every two hours as needed for shortness of breath/wheezing (abnormal lung sound) via (through) handheld nebulizer (HHN- a machine that deliver medicines in the form of aerosols) for 15 minutes or until the dose was completed. During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 had unclear speech, usually understood others, and sometimes made self understood. The MDS indicated Resident 25 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for personal hygiene, sit to stand and bed to chair transfers. During an observation on 6/14/2024 at 6:23 pm, in Resident 25's room and concurrent interview, Resident 25's facemask was placed in a plastic bag, and the facemask was not labeled with date of use. Resident 25 stated Resident 25 used the facemask for breathing therapy as needed. The IPN stated, Resident 25 used the facemask for breathing treatment as needed, as ordered by the physician. The IPN stated, Resident 25's facemask should be labeled with the date applied to Resident 25 and the mask needed to be changed every seven days or as needed. The IPN stated, this was to prevent accumulation of bacteria on the facemask that would cause health problems/complications to Resident 25. Based on observation, interview and record review, the facility failed to ensure residents receiving oxygen therapy (a treatment that provides with extra oxygen to breathe in) were provided necessary respiratory care and services for four of four sampled residents (Residents 25, 27, 151 and 199) in accordance with the facility's Policy and Procedure (P&P) on Respiratory Therapy - Prevention of Infection. These failures had the potential to result in respiratory complications and infection for Residents 25, 27, 151 and 199. Findings: a. During a review of Resident 151's admission Records (AR), the AR indicated Resident 151 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (muscle weakness on one side of the body), hemiparesis (a condition that causes weakness or inability to move on one side of the body) and pneumonitis (inflammation of the lungs). During a review of Resident 151's Order Summary Report (OSR), dated 6/7/2024, the OSR indicated Resident 151 had an order for oxygen to run at two (2) liters per (through) nasal cannula (L/NC, amount of oxygen delivered by nasal cannula [ NC- tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen] to keep oxygen saturation ( a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) above 92 percent (%). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 9 of 15 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 06/16/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 151's untitled Care Plan (CP), dated 6/7/2024, the CP indicated, Resident 151 was on oxygen at 2 L/NC to keep oxygen saturation above 92% related to aspiration pneumonia (a lung infection that occurs when a person breathes in bacteria-rich fluids, food particles, or other substances into their lower respiratory tract instead of swallowing them). During a review of Resident 151's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 6/11/2024, the MDS indicated Resident 151 had intact cognition (ability to understand). The MDS indicated Resident 151 required supervision or touching assistance (helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 151 required moderate assistance (helper does less than half the effort) with toileting and lower body dressing. During an observation on 6/14/2024 at 5:58 pm inside Resident 151's room, Resident 151 was coughing. Resident 151 was not using oxygen. Resident 151's oxygen tubing was on the floor. During an interview on 6/15/2024 at 11:32 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated when not in use, Resident 151's oxygen tubing should be placed inside the transparent bag intended for oxygen tubing and oxygen masks to prevent contamination and infection. During an interview on 6/15/2024 at 2:57 pm with the Infection Preventionist Nurse (IPN- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment), the IPN stated, when not in use, oxygen tubing should be placed inside the transparent bag to prevent contamination and respiratory infection to the resident (in general). During an interview on 6/16/2024 at 9:58 am with the Director of Nursing (DON), DON stated, Resident 151's oxygen tubing found on the floor needed to be replaced. The DON stated resident's (in general) oxygen tubing and tubing used for nebulization should be inside the transparent bag at bedside when not in use to prevent contamination of the tubing and to prevent infection. b. During a review of Resident 27's AR, the AR indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure (sudden condition when the lungs cannot get enough oxygen into the blood) and pneumonitis. During a review of Resident 27's untitled CP, dated 3/28/2024, the CP indicated Resident 27 was on oxygen at two (2) L/NC to keep oxygen saturation above 92% related respiratory failure. During a review of Resident 27's MDS, dated [DATE], the MDS indicated, Resident 27 had intact cognition. The MDS indicated Resident 27 required maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 27 was dependent (helper does all the effort, resident does none of the effort to complete the activity) with toileting, shower, and lower body dressing. During a review of Resident 27's OSR, dated 5/22/2024, the OSR indicated Resident 27 had an order for oxygen at 2L/NC, and for licensed staff to change oxygen tubing and oxygen humidifier bottle every Sunday and as needed. During an observation on 6/14/2024 at 6:39 pm inside Resident 27's room, Resident 27 was on oxygen at 2L/NC. Resident 27's oxygen tubing and oxygen humidifier bottle was not labeled with the date it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 10 of 15 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 06/16/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was changed. Resident 27 did not remember when Resident 27's oxygen tubing and oxygen humidifier was changed. During an interview on 6/14/2024 at 6:43 pm with the IPN, the IPN stated Resident 27's oxygen tubing and oxygen humidifier needed to be labeled with the date it was changed to ensure it was changed timely and as needed for infection control. During an interview on 6/14/2024 at 7:13 pm with Registered Nurse Supervisor 2(RN Sup 2), RN Sup 2 stated, oxygen tubing and oxygen humidifier bottle were changed every Sunday and as needed to prevent respiratory infection. During an interview on 6/16/2024 at 9:58 am with the DON, the DON stated, Resident 27's oxygen tubing and oxygen humidifier bottle should be labeled with the date it was changed to ensure it was changed as scheduled to prevent infection. d. During a review of Resident 199's AR, the AR indicated Resident 199 was admitted to the facility on [DATE] with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). During a review of Resident 199's History and Physical (H&P), dated 6/10/2024, the H&P indicated Resident 199 was alert and oriented. During a review of Resident 199's Physician Order's (PO), dated 6/7/2024, the PO indicated for Resident 199 to receive oxygen at 2 liters per minute (L/min) via NC continuously for hypoxia (low levels of oxygen in the body tissues) to keep oxygen above 92%. During an observation on 6/14/2024, at 6:28 pm in Resident 199's room, together with Licensed Vocational Nurse 5 (LVN 5), Resident 199 was lying in bed and Resident 199's oxygen tubing was touching the trash bin. LVN 5 stated Resident 199's oxygen tubing should not be touching the trash bin because the trash bin was dirty and would cause infection to Resident 199. During an interview on 6/14/2024, at 7:15 pm with Registered Nurse Supervisor 1 (RN Sup 1), RN Sup 1 stated Resident 199's oxygen tubing should not be touching the trash bin for infection control. During an interview on 6/15/2024, at 11:45 am with the facility's Director of Nurses (DON), the DON stated Resident 199's oxygen tubing should not be touching the trash bin to prevent cross contamination (the process by which bacteria or other microorganisms were transferred from one substance or object to another) resulting in respiratory infection. During a review of the facility's P&P titled, Respiratory Therapy - Prevention of Infection, dated November 2011, the P&P indicated, Mark bottle with date and initials upon opening and discard after 7 days or as needed. Change the oxygen cannula and tubing every 7 days, or as needed. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. The P&P further indicated, Infection control consideration related to medication nebulizers/continuous aerosol included to store the circuit in a plastic bag, marked with date and resident's name, in between uses. The P&P indicated to discard the administration set-up every seven (7) days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 11 of 15 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 06/16/2024 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision to a resident who used a plate guard (a dining aid that can help people with limited hand control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of two sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to result in Resident 1's decline in nutritional status and inability to maintain independence during mealtime. Findings: During a review of Resident 1's admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (a condition that causes weakness or inability to move on one side of the body). During a review of Resident 1's Order Summary Report (OSR), dated 7/24/2015, the OSR indicated Resident 1 had an order for plate guard at mealtime. During a review of Resident 1's untitled Care Plan (CP), dated 3/12/2021, the CP indicated Resident 1 was at risk for swallowing problem. The CP indicated Resident 1 was unable to use utensils and plate guard was provided with meals. The CP interventions included to inform all staff of resident's special dietary and safety needs, to provide plate guard at mealtime, and Resident 1 to eat only with supervision. During a review of Resident 1's OSR dated 4/24/2024, Resident 1 had an order for staff to provide feeding assistance to Resident 1 during meals. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/3/2024, the MDS indicated Resident 1 had moderately impaired cognition (ability to understand). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with eating and Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing and personal hygiene. During a review of Resident 1's Mini Nutritional Evaluation (MNE) dated 5/27/2024, the MNE indicated Resident 1 had a score of 11. A score of 11 indicated Resident 1 was at risk for malnutrition (lack of proper nutrition). During a review of Resident 1's Food Preference List (FPL) dated 6/13/2024, the FPL indicated Resident 1 was on mechanical soft (texture modified diet), chopped texture diet and Resident 1 preferred to use plate guard with meals. During a concurrent observation and interview on 6/14/2024 at 6:11 pm inside Resident 1's room with the Director of Nursing (DON), Resident 1 was eating dinner by himself using a plate guard. The plate guard opening was facing away from Resident 1. There was moderate amount of food spilled on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 12 of 15 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 06/16/2024 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's tray. The DON stated Resident 1 needed assistance to use the plate guard with meals to improve Resident 1's ability to eat on his own. During a concurrent observation and interview on 6/15/2024 at 8:20 am inside Resident 1's room with Certified Nurse Assistant 1 (CNA 1), CNA 1 assisted Resident 1 during breakfast. Resident 1 was using a plate guard with opening facing the resident. Resident 1 was eating, and food spilled in front of the tray and on Resident 1's bib. CNA 1 stated Resident 1 was right-handed. During an interview on 6/15/2024 at 9:48 am with the Dietary Supervisor (DS), DS stated Resident 1 preferred to use a plate guard with meals. DS stated the opening of the plate guard should be positioned on the resident's dominant hand or arm for the hand to have access on the plate guard and the hand could push food on the wall toward the plate guard to keep the food on the plate and off the table. During an interview on 6/16/2024 at 9:58 am with the DON, the DON stated plate guard opening should be positioned on the resident's stronger hand and arm to have access on the plate guard, scoop food better and minimized food spilling on the tray and clothes to maintain the resident's independence during mealtime. The DON stated, the opening of the plate guard could be adjusted depending on the resident's stronger hand and arm. During a review of the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, dated January 2020, the P&P indicated, The facility maintains and supervises the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents that may include specialized eating utensils and equipment. Recommendations for the use of assistive devices and equipment are based on the comprehensive assessment and documented in the resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 13 of 15 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 06/16/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was accurately documented for one of three sampled residents (Resident 25). This failure had the potential to result in miscommunication among health care providers, resulting in inconsistent care for the resident. Findings: During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 was admitted to the facility on [DATE], with diagnoses that included hydrocephalus (abnormal buildup of cerebrospinal fluid [fluid found within the tissues surrounding the brain] in the ventricles [cavities] within the brain) and hypertension (increased blood pressure). During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 had unclear speech, usually understood others, and sometimes made self understood. The MDS indicated Resident 25 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for personal hygiene, sit to stand and bed to chair transfers. During a review of Resident 25's POLST dated 10/31/2023, the POLST indicated Resident 25 had an Advance Directive (AD-a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]). During a review of Resident 25's AD acknowledgement form dated 4/1/2024, the AD acknowledgement form indicated Resident 25 did not execute an AD. During an interview and a concurrent record review on 6/15/2024 at 9:56 am, the Social Service Director (SSD) stated Resident 25 did not execute an AD. The SSD stated the SSD did an incorrect documentation on Resident 25's POLST indicating Resident 25 had an AD. The SSD stated there was inconsistency between Resident 25's POLST and AD acknowledgement form. The SSD stated it was important to document accurately in the resident's POLST because it would cause miscommunication among staff regarding resident's care and the resident would receive treatment against the resident's will in an emergency situation. During a review of the facility's Policy and Procedure (P&P) titled Charting and Documentation revised 7/2017, the P&P indicated Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 14 of 15 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 06/16/2024 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 23 rooms (rooms [ROOM NUMBERS]) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents. Findings: During an observation on 6/16/2024, from 9 am to 10:05 am, rooms [ROOM NUMBERS] did not meet the minimum requirement of 80 sq. ft. per resident. The residents in these rooms were able to ambulate freely and/or maneuver in their wheelchairs freely. Nursing staff had enough space to provide care to these residents with dignity and privacy. There was space for beds, side tables, dressers, and other medical equipment. During an interview with the Administrator (ADM) on 6/16/2024 at 11:02 am, regarding rooms [ROOM NUMBERS] that did not meet the minimum requirement of 80 sq. ft. per resident in multiple resident rooms, the ADM stated the ADM would submit a room waiver request for rooms [ROOM NUMBERS]. During a review of the facility's room waiver request letter dated 6/16/2024, the letter indicated there was ample room to accommodate wheelchairs and other medial equipment, as well as space for mobility and movement of ambulatory residents in rooms [ROOM NUMBERS]. The letter indicated there was adequate space for nursing care, and the health and safety of residents occupying rooms [ROOM NUMBERS] were not in jeopardy. The letter indicated rooms [ROOM NUMBERS] were in accordance with the special needs of the residents, and do not have an adverse effect on the resident's health and safety or impede the ability of any resident to attain his or her highest practicable well-being. The room waiver showed the following: Room Sq. Ft. Beds 12 156 2 32 156 2 The minimum square footage for 2-bed rooms is 160 sq ft. During interviews with residents both individually and collectively, the residents did not express any concerns regarding the size of their rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 15 of 15