Health inspection·December 21, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review of Resident 1's Care Plans on 12/21/2023 at 1:50 PM, the DON stated there was no Fall Risk Care Plan developed for Resident 1 after the Fall Risk Evaluation was completed. The DON stated Resident 1 should have a care plan to provide the necessary care and interventions because he is a fall risk. A review of the facility policy and procedure titled Fall Management Program, revised 3/3/2021, indicated as part of the admission assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident's care plan. Document interventions for every resident regardless of fall risk evaluation score. A review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, revised 11/2018, indicated if the comprehensive assessment and the comprehensive care plan identified a change in the resident's goals, or physical, mental or psychosocial functioning, which was not previously identified on the problem specific care plans used for the baseline care plan, those changes must be updated on each specific are plan used and incorporated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055760 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801 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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of dementia and severely impaired with cognition (thought process) was provided with adequate supervision, in accordance with the facility's policy and procedure on Resident Safety. This deficient practice resulted in Resident 1 eloping from the facility on 12/9/2023 from 12:50 PM to 1:21 PM (approximately 30 minutes), when the resident was left unsupervised while sitting on the wheelchair and was allowed to get out of the facility's backdoor. Resident 1 was found on the same day, 12/9/2023 after a police officer notified the facility to report that Resident 1 was brought by the Fire Department to the acute hospital. Resident 1 was readmitted back to the facility on [DATE] at 5:10 PM. Resident 1 sustained an abrasion to the forehead. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment of daily life). A review of Resident 1's History and Physical, dated 11/29/23, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool), dated 6/6/2023, indicated the resident was moderately impaired (decisions poor; cues/supervision required) of daily decision making. The MDS indicated Resident was severely impaired of cognition. The MDS indicated the resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance maybe provided throughout the activity or intermittently) while eating, showering/bathing and personal hygiene. Resident also required partial/moderate assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear. A review of Resident 1's Fall Risk Evaluation, dated 11/29/23, indicated Resident 1 is at risk for falls. A review of Resident 1's Progress Notes dated 12/9/2023, indicated the resident was not in his room at 1:10 PM. The Progress Notes indicated that a police officer came to that facility at 2 PM and stated that Resident 1 was found at one of the streets in another nearby city. The Progress Notes indicated that Resident 1 was brought by the Fire Department to the acute hospital. A review of Resident 1's Progress Notes dated 12/9/2023, indicated an IDT Note indicating Resident 1 was found a few blocks away from the facility and sustained an abrasion to the forehead. The Progress Notes indicated Resident 1 would be staying in the acute hospital for observation. A review of Resident 1's Progress Notes dated 12/10/2023, indicated Resident 1 was readmitted back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055760 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801 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 to the facility on [DATE] at around 5:10 PM. The Progress Notes indicated Resident 1 had an abrasion to the left lateral side of the face. During an interview on 12/21/2023 at 10:20 AM, Administrator (ADM) stated resident walked to the police department a block away from the facility. Residents Affected - Few During a concurrent interview and review of the facility's surveillance camera footage on 12/21/23 at 11:10 AM, and interview with the Administrator (ADM) and the Director of Nursing (DON), the DON stated there was no staff observed supervising the resident when the resident left the facility. The facility surveillance camera footage showed how the CNA (CNA1) was observed leaving Resident 1 unsupervised at the Nursing Station on 12/9/2023 timestamped at 12:33 PM. The facility surveillance camera footage showed Resident 1 got up from his wheelchair at 12:50 PM and left the facility and went out the backdoor at 12:51 PM. During an interview on 12/21/23 at 1:50 PM, the DON stated it is not appropriate to leave Resident 1 in the wheelchair unsupervised, especially if the resident is a fall risk and the resident should be supervised. A review of the facility policy and procedure titled Fall Management Program, revised 3 /3/2021, indicated the facility will implement a fall management program that supports providing an environment free from fall hazards. A review of the facility's policy and procedure titled Resident Safety, revised 4/15/2021, indicated its purpose is to provide a safe and hazard free environment. Policy also indicated the Interdisciplinary Team (IDT; members of different disciplines working collaboratively, with a common purpose, to set goals and make decisions for a resident) will establish a person centered observation or monitoring systems for the resident to address the identified risk factors identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055760 If continuation sheet Page 4 of 4