Health inspection·January 17, 2025

F 0625 Level of Harm - Minimal harm or potential for actual harm 2. Review of the facility's P&P titled Bed Hold Prior to Transfer revised 12/19/22, showed it is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. The facility will have a process in place to ensure the residents and/or their representatives are made aware of the facility's bed-hold and reserve bed payment policy well in advance of being transferred to the hospital. Residents Affected - Few Review of the facility's P&P titled Bed Hold Notice Upon Transfer revised 12/19/22, showed at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident. Review of Resident 1's Notice of Transfer/discharge date d 12/30/24, showed Resident 1 was transferred to the acute care hospital because the transfer/discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. Further review of Resident 1's medical record failed to show Resident 1 and/or the resident's representative were informed of the facility's bed hold policy before transferring to the acute care hospital on [DATE]. On 1/17/25 at 1528 hours, an interview and concurrent medical record review was conducted with the DON and RN Consultant. The DON and RN Consultant verified there was no bed hold information was provided to Resident 1 and/or the resident's representative prior to Resident 1 transferring to the acute care hospital on [DATE]. On 1/17/25 at 1640 hours, the Administrator was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055622 If continuation sheet Page 2 of 7 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of disease and infections. Residents Affected - Few * Resident 2 who had salmonella was cohorted with Resident 1 who did not have salmonella. * RN 1 failed to perform hand hygiene and don the gloves and gown on while providing care for Resident 2 who was on contact isolation precautions. * The facility failed to ensure a visitor donned the gloves and gown on while sitting on Resident 2's bed. * The facility failed to ensure Caregiver 1 donned a gown on while feeding Resident 1 who was inside an isolation room for a contact precaution. Findings: 1. Review of the facility's P&P titled Transmission-Based (Isolation) Precautions revised 7/18/23, showed it is the policy to take appropriate precautions to prevent transmission of pathogens, based on pathogens' modes of transmission. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Transmission-based precautions (Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. When implementing transmission-based precaution, the facility will consider the following: cohorting residents with the same pathogen; and sharing a room with a roommate with limited risk factors (example, without indwelling or invasive devices, without open wounds, and not immunocompromised) as appropriate based on the pathogen and method of transmission. a. Medical record review for Resident 1 was initiated on 1/17/25. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had a BIMS score of two, indicating severe cognitive impairment. Review of Resident 1's MAR for January 2025 showed Resident 1's medications were administered via G tube. Review of Resident 1' s TAR for January 2025 showed wound treatments were provided to Resident 1's abdominal area for the stoma/G tube, coccygeal, right forehand, and scrotal skin tear. Further review of Resident 1's medical record failed to show Resident 1 required a contact isolation precautions and/or had salmonella infection. b. Medical record review for Resident 2 was initiated on 1/17/25. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055622 If continuation sheet Page 3 of 7 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's MDS dated [DATE], showed Resident 2 had a BIMS score of three, indicating severe cognitive impairment. Review of Resident 2's Order Summary Report showed a physician's order dated 1/8/25, for contact isolation related to salmonella. Residents Affected - Few On 1/17/25 at 1238 hours, an interview was conducted with LVN 1. LVN 1 stated Residents 1 and 2 were both totally dependent on the staff for their care and both residents had G tubes. LVN 1 verified Resident 2 was on contact isolation precaution and stated Resident 1 should not be cohorted with Resident 2 because of the high risk for contamination for Resident 1. On 1/17/25 at 1330 hours, an interview and concurrent medical review was conducted with RN 1. RN 1 verified Resident 1 should not be cohorted with Resident 2 because Resident 1 was not infected with salmonella. RN 1 stated both Residents 1 and 2 shared the same bathroom with only one sink to use so there was a high risk for contamination for Resident 1. On 1/17/25 at 1528 hours, an interview and concurrent medical review was conducted with the DON and RN Consultant. The DON verified Resident 1 should not be cohorted with Resident 2 because of the high risk for contamination for Resident 1. 2. Review of the facility's P&P titled Standard Precautions Infection Control revised 12/19/22, showed all the staff members are to assume that all the residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all the staff members shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Under the Policy Explanation and Compliance Guidelines section, showed the following: 1. Hand hygiene: (a) during the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. (b) Perform hand hygiene. 2. Using personal protective equipment (PPE): all staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. On 1/17/25 at 1220 hours, an observation was conducted on Room C. At the entrance of the room, a contact precaution sign was posted. The sign showed the following: -Everyone must clean their hands, including before entering and when leaving the room. -Providers and staff must also put on gloves before room entry. -Discard gloves before room exit. -Put on gown before room entry. -Discard gown before room exit. a. On 1/17/25 at 1223 hours, an observation and concurrent interview was conducted with RN 1. RN 1 was observed not performing hand hygiene before entering and leaving Room C. Furthermore, RN 1 was observed without gloves and gown while touching the enteral pump button of Resident 2 inside Room C. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055622 If continuation sheet Page 4 of 7 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm RN 1 verified the above findings and stated it was important to perform hand hygiene and don the proper PPE when going into a contact precaution room for infection control. b. On 1/17/25, at 1520 hours, an observation was conducted on Room C. Resident 2's visitor was observed sitting on the resident's bed without gloves and gown. LVN 1 verified the above findings. Residents Affected - Few c. On 1/17/25 at 1230 hours, an observation and concurrent interview was conducted with Caregiver 1 inside Room C. Caregiver 1 was observed wearing a mask and gloves while feeding Resident 1. When asked, Caregiver 1 stated she did not know a gown should be worn while inside a contact precaution room. Caregiver 1 further stated the facility did not provide her training or education regarding contact precaution. On 1/17/25 at 1640 hours, the Administrator, DON, and RN Consultant were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of disease and infections. * Resident 2 who had salmonella was cohorted with Resident 1 who did not have salmonella. * RN 1 failed to perform hand hygiene and don the gloves and gown on while providing care for Resident 2 who was on contact isolation precautions. * The facility failed to ensure a visitor donned the gloves and gown on while sitting on Resident 2's bed. * The facility failed to ensure Caregiver 1 donned a gown on while feeding Resident 1 who was inside an isolation room for a contact precaution. Findings: 1. Review of the facility's P&P titled Transmission-Based (Isolation) Precautions revised 7/18/23, showed it is the policy to take appropriate precautions to prevent transmission of pathogens, based on pathogens' modes of transmission. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Transmission-based precautions (Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. When implementing transmission-based precaution, the facility will consider the following: cohorting residents with the same pathogen; and sharing a room with a roommate with limited risk factors (example, without indwelling or invasive devices, without open wounds, and not immunocompromised) as appropriate based on the pathogen and method of transmission. a. Medical record review for Resident 1 was initiated on 1/17/25. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had a BIMS score of two, indicating severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055622 If continuation sheet Page 5 of 7 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's MAR for January 2025 showed Resident 1's medications were administered via G tube. Review of Resident 1' s TAR for January 2025 showed wound treatments were provided to Resident 1's abdominal area for the stoma/G tube, coccygeal, right forehand, and scrotal skin tear. Residents Affected - Few Further review of Resident 1's medical record failed to show Resident 1 required a contact isolation precautions and/or had salmonella infection. b. Medical record review for Resident 2 was initiated on 1/17/25. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 had a BIMS score of three, indicating severe cognitive impairment. Review of Resident 2's Order Summary Report showed a physician's order dated 1/8/25, for contact isolation related to salmonella. On 1/17/25 at 1238 hours, an interview was conducted with LVN 1. LVN 1 stated Residents 1 and 2 were both totally dependent on the staff for their care and both residents had G tubes. LVN 1 verified Resident 2 was on contact isolation precaution and stated Resident 1 should not be cohorted with Resident 2 because of the high risk for contamination for Resident 1. On 1/17/25 at 1330 hours, an interview and concurrent medical review was conducted with RN 1. RN 1 verified Resident 1 should not be cohorted with Resident 2 because Resident 1 was not infected with salmonella. RN 1 stated both Residents 1 and 2 shared the same bathroom with only one sink to use so there was a high risk for contamination for Resident 1. On 1/17/25 at 1528 hours, an interview and concurrent medical review was conducted with the DON and RN Consultant. The DON verified Resident 1 should not be cohorted with Resident 2 because of the high risk for contamination for Resident 1. 2. Review of the facility's P&P titled Standard Precautions Infection Control revised 12/19/22, showed all the staff members are to assume that all the residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all the staff members shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Under the Policy Explanation and Compliance Guidelines section, showed the following: 1. Hand hygiene: (a) during the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. (b) Perform hand hygiene. 2. Using personal protective equipment (PPE): all staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. On 1/17/25 at 1220 hours, an observation was conducted on Room C. At the entrance of the room, a contactprecaution sign was posted. The sign showed the following: -Everyone must clean their hands, including before entering and when leaving the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055622 If continuation sheet Page 6 of 7 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Providers and staff must also put on gloves before room entry. Level of Harm - Minimal harm or potential for actual harm -Discard gloves before room exit. -Put on gown before room entry. Residents Affected - Few -Discard gown before room exit. a. On 1/17/25 at 1223 hours, an observation and concurrent interview was conducted with RN 1. RN 1 was observed not performing hand hygiene before entering and leaving Room C. Furthermore, RN 1 was observed without gloves and gown while touching the enteral pump button of Resident 2 inside Room C. RN 1 verified the above findings and stated it was important to perform hand hygiene and don the proper PPE when going into a contact precaution room for infection control. b. On 1/17/25, at 1520 hours, an observation was conducted on Room C. Resident 2's visitor was observed sitting on the resident's bed without gloves and gown. LVN 1 verified the above findings. c. On 1/17/25 at 1230 hours, an observation and concurrent interview was conducted with Caregiver 1 inside Room C. Caregiver 1 was observed wearing a mask and gloves while feeding Resident 1. When asked, Caregiver 1 stated she did not know a gown should be worn while inside a contact precaution room. Caregiver 1 further stated the facility did not provide her training or education regarding contact precaution. On 1/17/25 at 1640 hours, the Administrator, DON, and RN Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055622 If continuation sheet Page 7 of 7