Health inspection·February 26, 2026

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete room at 11:40 AM, [NAME] 1 was observed wiping food contact surfaces with a kitchen towel, then stored the kitchen towel on the counter. During a concurrent observation and interview with [NAME] 1 on 2/24/2026 at 11:40 AM, [NAME] 1 stated, kitchen towels should be stored in a sanitizer solution when not in use. [NAME] 1 stated the kitchen towel was from the kitchen and they do not have a sanitizer solution in the conference room to store the towels. [NAME] 1 stated it is important to clean the counters with kitchen cloth and sanitizer because it sanitizes the counters so there is no contamination. During an interview with DS on 2/24/2026 at 11:45 AM, DS stated a sanitizer solution bucket should be in the conference room. DS stated the sanitizer solution bucket was left in the kitchen. DS returned with sanitizer solution in a red bucket. During the same interview with DS on 2/24/2026 at 11:50 AM, the DS stated kitchen staff could not check the sanitizer solution since there were no sanitizer strips in the conference room, therefore staff could not tell if the sanitizer solution was effective. DS stated it was important to have the sanitizer solution test strips to monitor the effectiveness of the sanitizer and to make sure food contact surfaces are sanitized. During a review of facility's P&P titled, Food Safety and Food Storage, revised 11/2024, the P&P indicated, staff shall adhere to safe hygienic practices to prevent contamination of foods from hands on physical objects. Dietary staff must wear hair restraints (e.g. hairnet, hat and or beard restraint) to prevent hair form contacting food. During a review of facility P&P titled, Sanitizer use concentrations for food service and food production facilities, revised 4/2020, the P&P indicated, sanitation buckets must be established with appropriate sanitizing solution.sanitizing cloths should be placed in the sanitizing buckets to be used for sanitizing all work surfaces and equipment. Dietary should change these buckets at least 3 times a day and test with the appropriate test strips each time the solution is changed to ensure accurate levels of sanitizer.Some corporations require red sanitizing buckets. A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:(1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; 3. During an observation of the lunch service in the conference room on 2/24/2026 at 11:30 AM, a temperatures check of the milk was conducted using the facility's thermometer. The obtained temperature registered the milk temperature at 52.5 degrees Fahrenheit (F). During a concurrent observation and interview with DS and dietary aide (DA) 1, DA 1 stated the beverages were stored in the freezer in the kitchen to ensure they were very cold when brought up to the conference room. DS stated the conference room gets warm during meal service and temperatures of cold beverage did not stay at 41degrees F or lower. DS stated there was no ice in the conference room to store the beverages on ice before meal services. DS stated if room temperature milk was served to residents, residents would complain, and if milk was left out too long, the milk would go bad. During a review of the facility's P&P titled food Safety and Food Storage, revised 11/2024, the P&P indicated, when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards.Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger zone. During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below. Event ID: Facility ID: 055989 If continuation sheet Page 2 of 6 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure a QA/QAPI (Quality Assurance/Quality Assurance and Performance improvement, a date driven proactive approach to improvement used to ensure services are meeting quality standards) plan was developed on how to monitored interventions put in place related to the inoperable elevator from and to the kitchen and food service in the conference room by failing to: 1. Safe and sanitary food storage and distribution practices in the conference room. 2. Staff received ongoing training and evaluations of their skills and knowledge to ensure safe food receipt and delivery procedure, safe and sanitary food distribution to residents and reduced risk of injury. 3.Food items were received and handled in a safe and sanitary manner from suppliers. This deficient practice had the potential for unsanitary and unsafe food storage and distribution practices that can result in food poisoning or foodborne illnesses (gastrointestinal infection due to consumption of contaminated food with toxins from bacteria, virus or parasites). Cross reference to F812 and F921Findings: During a concurrent observation and interview with Assistant Administrator (AADM) and Maintenance Supervisor (MS) on 2/24/2026 at 10:30AM, The facility conference room was used as a food distribution and serving area. During a concurrent interview with AADM and MS on 2/24/2026, AADM stated that the elevator has been broken since the last quarter of 2024. AADM stated kitchen is in the basement and food is being delivered by staff through the stairwell and into the conference room. During the same observation in the conference room on 2/24/2026 at 10:30AM there was one sandwich with a date of 2/22/26- 2/23/2026 expired stored in the reach in refrigerator. During an observation in the kitchen located in the basement on 2/24/2026 at 11:00AM, Dietary Aide (DA1) was carrying beverages including juices and milk in cups on a tray up the stairs. During a concurrent observation and interview with Dietary Supervisor (DS) on 2/24/2026 at 11:05AM, DS stated elevator broke down in October 2024 and since then, they have been using the stairwell to carry food and receive the deliveries that are left in the parking lot. DS stated during this time only one staff member was injured, DS stated no in-service related to fall injuries and fall prevention were provided. During an observation in the basement on 2/24/2026 at 11:08AM Cook1 and DA2 are taking large pans of food upstairs. During an observation in the conference room for lunch service on 2/24/2026 at 11:30AM, Food and beverages temperatures were checked using facility thermometer. The temperature of the cold beverage apple juice was 46.9 degrees Fahrenheit ( F). The temperature of the milk was 52.5 F. During a concurrent observation and interview with DS on 2/24/2026 at 11:30AM, DS stated the conference room is warm during service time, there is no ice in the conference room to store the beverages while serving. DS stated cold food and beverages should have a temperature of 41 F degrees and below. During a concurrent observation and interview with DA3 and DS in the basement on 2/24/2026 at 1:00 PM DS stated food and supplies are delivered 2-3 times week. DS stated the food delivery vendors used to bring all the food deliveries through the elevator to the kitchen. DS stated that now food vendors leave the food in the parking lot and kitchen staff bring it to the basement using the stairwell. During an interview with the Administrator (ADM) on 2/26/2026 at 10:30AM, the ADM stated the facility meets monthly for the QA meeting and since the elevator broke on 10/2024, the QA meeting has discussed the replacement of the elevator. The ADM stated the committee talks about the elevator outage during QA meetings but could not show me documentation that they had a performance improvement project or have been monitoring the sanitation and infection control in the upstairs conference room where food is being served. The ADM stated they take every injury seriously but have not implemented routine ongoing training to assess skills and risk of injury of staff who transport food through the stairwell. ADM stated it is very important to monitor the new procedures to make sure if the temporary Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055989 If continuation sheet Page 3 of 6 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete food service system needs improvement or change. The ADM stated elevator repair takes a long time and it is a slow approval process, also to monitor data of different quality measures takes time and they have not done it as part of their QAPI. During an interview with Dietary Supervisor (DS) on 2/26/2026 at 11:30AM, DS stated facility Registered Dietitian does a monthly sanitation audit in the kitchen which includes making sure food is stored safely, and staff are following good hygiene practices. DS stated the monthly audit does not include the conference room where food is temporarily being served due to the elevator outage. DS stated staff are not routinely trained in injury risk prevention while delivering food through the stairwell. DS stated while we make sure delivered food items that are cold and perishable are brought downstairs to the kitchen and stored first; we have not established a monitoring and audit system to make sure cold food stays cold during delivery. During a review of facility policy and procedures (P&P) titled, Quality Assessment and Assurance Committee (dated 12/19/2022), the p&p indicated, the facility will maintain a quality Assessment and Assurance (QAA) committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies thought an interdisciplinary approach. The committee will: c: identify and respond to quality deficiencies thought the facility; d: develop and implement corrective plans of action and monitor to ensure performance goals or targets are achieved and sustained; e: Revise corrective action as necessary, based on QAA committee monitoring and evaluation. Event ID: Facility ID: 055989 If continuation sheet Page 4 of 6 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to maintain safe and functional environment by ensuring the elevator from the kitchen was maintained in functioning condition to maintain sanitary and safe food service for all residents in the facility and staffs. As a result, resident food was carried by the staff from basement through the stairwell, food distribution and service is relocated to the conference room, food vendors leave food deliveries in the parking lot to be carried by kitchen staff through the stairwell. This deficient practice had the potential to result in unsafe and unsanitary food storage and distribution practice and place staff at risk of injuries.Findings: During a concurrent observation and interview with Assistant Administrator (AADM) and Maintenance Supervisor (MS) on 2/24/2026 at 10:30AM, the facility conference room was being used by the facility as a food distribution and serving area for the residents. During the same observation on 2/24/2026 at 10:30AM, in the conference room, there was a steam table (used to hold precooked food at safe temperatures >135 degrees F; has multiple stainless-steel compartments (wells) that use heated water to produce steam and keep food warm), a plate warmer, one refrigerator (vertical commercial refrigerator with a from opening doors) meal carts (carts with shelves to transport food) and a fan. During a concurrent interview with AADM and MS on 2/24/2026 at 10:40 AM, the AADM stated that the elevator has been broken since last quarter of 2024. AADM stated the kitchen was in the basement and food was being delivered by staff through the stairwell and into the conference room. AADM stated the facility have tried different places and different methods to serve food, and the conference room has been the location that works out the best to serve food for the residents. AADM stated food delivery service has been relocated to the conference room to set up the trays, because the elevator was not working and the kitchen is in the basement. During the same interview on 2/24/2026 at 10:40 AM, the MS stated before the elevator broke in 2024, there were problems with the elevator, and the repair company was always providing maintenance. The MS stated, the repair company informed the facility that the elevator should be replaced. MS stated after 10/2024 no repair was done for this elevator. MS stated has copies of all the repairs reports from the elevator repair company. During an observation in the kitchen located in the basement on 2/24/2026 at 11:00AM, Dietary Aide (DA1) was carrying beverages including juices and milk in cups set up on a tray up the stairs. Observed DA1 going up and down stairs 4 times to deliver the trays of beverages. DA1 was observed breathing fast and observed sweat on forehead, face and neck. During a concurrent observation and interview with DA1 on 2/24/2026 at 11AM, DA1 acknowledged being warm and sweating from going up and down the stairs. During a concurrent observation and interview with Dietary Supervisor (DS) on 2/24/2026 at 11:05AM, DS stated elevator broke down in October 2024 and since then, the facility have been using the stairwell to carry food and receive food deliveries from vendors. DS stated during this time one staff member was injured, DS stated the facility had not provided in-services related to safety in deliver food and prevent fall injuries and fall prevention. During an observation in the basement on 2/24/2026 at 11:08AM Cook1 and DA2 are taking large pans of food via stairway to the conference room upstairs. During an observation in the conference room for lunch service on 2/24/2026 at 11:30AM, Food and beverages temperatures were checked using facility thermometer. The temperature of the cold beverage apple juice was 46.9 degrees Fahrenheit ( F)The temperature of the milk was 52.5 F. During a concurrent observation and interview with DS on 2/24/2026 at 11:30AM, DS stated the conference room is warm during service time, there was no ice in the conference room to store the beverages while serving. DS stated cold food and beverages should have a temperature of 41 F and below during holding time (hold time-time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055989 If continuation sheet Page 5 of 6 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete when food is stored before and during service). During a concurrent observation and interview with DA3 and DS in the basement on 2/24/2026 at 1:00 PM DS stated food and supplies are delivered 2-3 times week. DS stated the food delivery vendors used to bring all the food deliveries through the elevator to the kitchen. DS stated that now food vendors leave the food in the parking lot and kitchen staff bring it to the basement using the stairwell. During a concurrent interview with DA3 on 2/24/2026 at 1:00PM, DA3 states after food vendor delivers the food in the parking lot, DA3 brings the perishable food such as milk and dairy products first to the kitchen. DA3 states takes 3 gallons of milk at a time and brings it down the stairs to the kitchen. DA3 states takes 2 hours to bring supplies when working alone. DA3 states when dairy products left outside for long time, they can go bad. During an interview with ADM on 2/26/2026 at 10:30AM ADM stated they tried to fix the elevator several times, but then it was not repairable and needed to be replaced. ADM stated they did not try to repair it further since they were told by elevator repair company that it needed to be replaced. ADM stated the elevator failed in October 2024. ADM stated notified HCAI (department of healthcare access and information) on 10/2025 of the elevator replacement project but did not notify the district office of the existing inoperable elevator. During a review of a report from the elevator company titled Maintenance Time Ticket dated 4/4/2024 the maintenance report indicated, recommend replacing oil, cleaning valves, change [NAME], packing and doing 5-year load test During a review of the Maintenance Time Ticket dated 5/23/24, 7/26/24; 7/31/24; 8/2/2024 report did not indicate the recommended services from previous months were done. During a review of the Maintenance Time Ticket dated 8/21/2024 indicated, report due emergency alarm bell not working found broken wire replaced and checked return to service. During a review of the Maintenance Time Ticket dated 9/9/2024 indicated a routine maintenance was completed. There is no other maintenance completed on the elevator after 9/9/2024. During a review of facility Program Flexibility request dated 2/23/2026, the program flexibility indicated, A temporary meal staging area has been established in the upstairs conference room to support service during the elevator outage. During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below. During a review of facility policy and procedure(P&P) titled, Food safety and Food Storage (revised 11/2024) the P&P indicated, When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. Holding: staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. During a review of facility policy and procedure(P&P) titled, Food safety and Food Storage (revised 11/2024) the P&P indicated, Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the danger zone. Strategies include Timely distribution of all meals/snacks. During a review of facility policy and procedure(P&P) titled, Food safety and Food Storage (revised 11/2024) the P&P indicated, refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. During a review of facility policy and procedures titled Receiving Food and Supplies (revised 2/2019) the policy and procedure indicated, Food items should be received and handled in accordance with good sanitary practice. Keep cold food at room temperature for a minimum length of time. Do not allow cold foods to rise greater than 41degrees F or frozen foods to thaw. Event ID: Facility ID: 055989 If continuation sheet Page 6 of 6