Health inspection·January 19, 2024

F 0558 directly for assistance from his/her bed, from toileting/ bathing facilities and from the floor. 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: 056201 If continuation sheet Page 2 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) to address resident's central venous catheter (a type of access used for hemodialysis [a procedure removing metabolic waste products or toxic substances from the bloodstream]) for one (1) of 18 sampled resident (Resident 160). This deficient practice had the potential to not be able to provide the specific interventions such as monitoring Resident 160's access site for bleeding and infection, which could result in harm. Findings: A review of Resident 160's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 160's diagnoses included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis (process of removing waste products and excess fluid from the body), and hypertension (high blood pressure). A review of Resident 160's care plan initiated on 12/12/23, indicated Resident 160 was receiving hemodialysis and was potential for post-dialysis complications such as respiratory compromise, chest pain, fatigue, low blood pressure (BP), leg cramps, headaches, nausea/vomiting (N/V), itchy skin, infection, excess bleeding secondary to heparin (blood thinner) use during dialysis treatment. It also indicated that Resident 160 was at risk of clotting of Arteriovenous (AV) shunt (a surgically created connection between vein and artery). The care plan interventions indicated the following: In case of bleeding apply pressure to the access site and notify Medical Doctor (MD). May give routine medications to resident up to two (2) hours early on days of dialysis. Monitor labs/diagnostic tests as ordered and notify MD of results Monitor pre- and post- dialysis weight (resident weighed before and after dialysis treatment in dialysis center) Notify MD if resident presents with s/s of infection, respiratory compromise, chest pain, fatigue, low BP, leg cramps, headaches, N/V, itchy skin, edema worsening or unresolving, or bleeding. A review of Resident 160's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/2/24, indicated Resident 160's cognition (ability to think and reason) was intact. The MDS indicated Resident 160 required partial assistance (helper does more than half the effort) with eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene. It also indicated Resident 160 was dependent with shower, lower body dressing, and putting on/taking off footwear. A review of Resident 160's order summary report, dated 1/19/24, indicated an order on 12/29/23 to monitor dialysis site, right upper chest tunnel catheter (a flexible catheter [thin tube] that goes into a vein in your chest) for tenderness, redness or bleeding every shift, document findings outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 3 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 of baseline and call MD. Level of Harm - Minimal harm or potential for actual harm During a concurrent record review of Resident 160's order summary report and care plan, and interview on 1/19/24 at 2:26 PM with LVN 1, LVN 1 verified that Resident 160's order on 12/29/23 is to monitor dialysis site, which was the right upper chest tunnel. LVN 1 stated Resident 160's care plan indicated AV shunt instead of the right upper chest tunnel. LVN 1 stated care plan should have been indicated the correct dialysis site because the care and monitoring for the right upper chest tunnel which is a central venous catheter is different from AV shunt care and monitoring. Residents Affected - Few During a concurrent record review of Resident 160's order summary report and care plan, and interview on 1/19/24 at 2:45 PM with Registered Nurse (RN) 1, RN 1 verified that Resident 160's care plan was inaccurate because it indicated an AV shunt which Resident 160 never had. RN 1 stated that Resident 160 has a right upper chest tunneled central catheter, which was on the Resident 160's dialysis order. RN 1 stated that it was important to reflect the right dialysis access and appropriate interventions on the care plan for the entire care team to know the specific care for Resident 160's dialysis access. RN 1 stated Resident 160's physician order on 12/29/23 to monitor dialysis site, right upper chest tunnel, for tenderness, redness or bleeding every shift, document findings outside of baseline and call MD should have been included in Resident 160's care plan. A review of the facility's policy and procedure titled, Renal Dialysis, Care of Residents, revised December 2013, indicated It is the policy of this Facility to follow standards of care for residents receiving renal dialysis. It also indicated dialysis care plan documentation to have pertinent data available for all caregivers of dialysis residents to provide quality care. And the Facility will document the following Dialysis order information in the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 4 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, facility failed to meet professional standards to ensure a neurological assessment ( a group of questions and tests to check for disorders of the nervous system [sends messages back and forth between the brain and the body]) was completed for two (2) of 18 sampled residents (Resident 38 and Resident 52) who had a fall, in accordance with the facility's policy and procedure (P&P). Residents Affected - Few This deficient practice had the potential to result in a delay of care and services, which could negatively affect Residents 38 and 52's overall wellbeing. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 12/1/24. Resident 38's diagnoses included were history of falling, anxiety (persistent and excessive worry that interferes with daily activities), and muscle weakness. A review of Resident 38's Minimum Data Set (MDS, standardized care and screening tool), dated 12/11/23, indicated Resident 38 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 38 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene, toileting hygiene, shower / bathe self, and personal hygiene. Substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort. A review of Resident 38's Post Fall Review, dated 1/17/24 timed at 4:45 PM, indicated Resident 38 had a fall at South station. Resident 38 was found lying on the left side position on the floor. It indicated immediate action taken was completion of initial neurological check. A review of Resident 38's Care Plan, initiated 12/27/23, indicated staff Interventions were to notify MD (doctor) of unwitnessed fall, continue neuro check, and for orthostatic blood pressure (obtained and recorded while the resident is lying on the back position as well as in the standing position) monitoring. A review of Resident 38's Care Plan, initiated 1/17/24, indicated an actual incident of fall on 1/17/24 related to trying to get up unassisted, poor safety awareness, unsteady gait, impaired vision, and poor posture. Staff intervention included was to initiate 72 hours neuro check for witnessed fall injury. 2. A review of Resident 52's admission Record indicated the facility admitted Resident 52 on 12/6/24. Resident 52's diagnoses included were difficulty in walking, lack of coordination, and anemia (condition in which the body does not have enough healthy red blood cells). A review of Resident 52's Minimum Data Set (MDS, standardized care and screening tool), dated 12/11/23, indicated Resident 52 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 52 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on toileting hygiene, shower / bathe self, and putting on taking off footwear. Partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 5 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0658 support trunks or limbs, but provides less than half the effort) on oral hygiene and personal hygiene. Level of Harm - Minimal harm or potential for actual harm A review of Resident 52's Post Fall Review, dated 1/16/24 at 6:50 AM, indicated Resident 52 was found sitting upright on the floor next to the wheelchair and bed. It indicated immediate actions taken were completion of initial neurological check and head to toe assessment which revealed resident was able to move all extremities. Residents Affected - Few During an interview on 1/18/24 at 3:59 PM., with license vocational nurse 1 (LVN 1) stated they used the Neurological Assessment Flow sheet form to conduct Neuro check. LVN 1 further stated she does not check the size of the pupil. During a concurrent interview and record review on 1/19/24 at 3:00 PM., with the director of nursing (DON), DON stated the neurological assessment flowsheet form they used for Resident 38 and Resident 52 was an old form. The old form does not have Glasgow Coma Scale ([GCS] used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses) assessment, orientation and sensation. Without GCS assessment, orientation and sensation, the assessment would not be accurate. During a review of facility's policies and procedure (P&P) titled, Neurological Assessment, revised 10/2010, indicated: Purpose: The purpose of this procedure is to provide guidelines for neurological assessment: 1) upon physician order 2) when following an unwitnessed fall 3) subsequent to fall with suspected head injury. 4) when indicated by resident condition. Steps in the procedure indicated: 4) determine residents the resident's orientation to time, place and person. 7) check pupil reaction: c. turn on flashlight and observe size and reaction of pupil. 12) check eye opening, verbal and motor responses using the GCS. Record observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 6 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the safety for one of two sampled residents (Resident 38) for accident care area, by not monitoring and supervising the resident. Residents Affected - Few This deficient practice resulted to Resident 38's fall (move downward, typically rapidly and freely without control, from a higher to a lower level) on 12/27/23 and 1/17/24. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 12/1/20. Resident 38's diagnoses included were history of falling, anxiety (persistent and excessive worry that interferes with daily activities) and muscle weakness. A review of Resident 38's Minimum Data Set (MDS, standardized care and screening tool), dated 12/11/23, indicated Resident 38 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 38 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene, toileting hygiene, shower / bathe self, and personal hygiene. Substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort. During a review of Resident 38's Progress Notes, dated 12/27/23, timed at 11:15 AM, indicated Resident 38 was found sitting on the floor. The care plan did not indicate resident specific intervention to another fall such as supervising the resident. During a review of Resident 38's Progress Notes, dated 1/17/24, timed at 11:08 PM, indicated At around 6:45 PM, the resident had a fall at the south station. Resident 38 was noted with redness on left shoulder and left thigh. The nurse practitioner (NP) order to transfer Resident 38 to General Acute Care Hospital 1 (GACH 1) emergency room for further evaluation. During a review of Resident 38's Care Plan, initiated 1/17/24, indicated actual incident of fall on 1/17/24 related to trying to get up unassisted and poor safety awareness. During concurrent interview and record review on 1/19/24 at 10:09 AM, with the infection preventionist nurse (IPN), Resident 38's care plan for fall dated 12/17/23 was reviewed. The IPN stated the care plan did not indicate interventions to prevent Resident 38 from having another fall such as monitoring or supervising the resident. The IPN stated, on 1/17/24 Resident 38 was on her wheelchair socializing with other residents at the South Nursing Station when Resident 38 had an unwitnessed fall from her wheelchair. IPN also stated it was possible that the staff was in the middle of med-pass (passing medication to residents) or making endorsements when the fall incident happened. IPN further stated if Resident 38 was supervised and monitored, the fall can be prevented. During concurrent record review of Resident 38's Care Plan, dated 12/27/23 for fall and interview on 1/19/24 at 2PM, the director of nursing (DON) stated, Resident 38's care plan did not indicate any specific intervention to avoid fall for Resident 38. The DON also stated, the staff will implement new person-centered care plan to reduce risk factor for residents that had frequent fall incidents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 7 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of facility's policies and procedure (P&P) titled, Managing Falls and Fall Risk, revised 3/2018, indicated based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. During a review of facility's policies and procedure (P&P) titled, Fall Risk Assessment, revised 3/2018, indicated under policy interpretation and implementation, the staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Event ID: Facility ID: 056201 If continuation sheet Page 8 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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** Based on interview and record review, the facility failed to remove an intravenous (IV, within the vein) catheter saline lock (a thin plastic tube that is threaded into a vein, flushed with saline, and then capped off for later use) that was inserted for more than 96 hours for one (1) of 18 sampled residents (Resident 258), as indicated on the facility policy. Residents Affected - Few This failure had the potential to put Resident 258 at risk for developing an infection. Findings: During a review of Resident 258's admission Record, it indicated the resident was admitted to the facility on [DATE] with admitting diagnoses of fracture (broken bone) of the left humerus (bone in the arm), hypertension (high blood pressure even at rest), acute sinusitis (infection and inflammation of the sinus), and history of falling. During a review of Resident 258's History and Physical, dated 1/14/24, it indicated the resident has the capacity to understand and make decisions. During a review of Resident 258's hospital report titled, Hospital Record on New Admission, dated 1/11/24, it indicated the resident was admitted to the facility with an IV on the left arm. During a record review of Resident 258's care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs), an entry on 1/11/24 indicated the resident is to receive ceftriaxone (an antibiotic- medication used to treat bacterial infections) via the resident's IV once a day for acute sinusitis for five days. During a concurrent interview and record review on 1/18/24 at 1:53 PM with Director of Nursing (DON), the nurses' progress notes for Resident 258 was reviewed. The DON stated there is documentation on the progress notes on 1/16/24 at 6:59 PM that the IV on the left arm was still intact. The DON stated she administered the last dose of the resident's antibiotic using the IV on the left arm on 1/16/24. During a concurrent a record review of Resident 258 nurses' progress notes and interview and on 1/18/24 03:36 PM with Registered Nurse 1 (RN 1), RN 1 stated there was no documentation indicating that Resident 258's IV on the left arm was removed or that the site was changed since 01/11/24. RN 1 also stated according to the facility's IV therapy policy and procedure (P&P), the IV on the left arm should have been removed on or before 01/15/24. RN stated there was no physician order to extend the use of the IV on the left arm. During an interview on 1/19/24 at 3:53 PM, the DON stated that the IV on the left arm was inserted before Resident 258's admission to the facility on 1/11/24. The DON stated according to the facility's IV therapy P&P titled, General Policies for IV Therapy, dated June 2018, the IV on the left arm should have been removed on or before 1/15/24. The DON stated she should not have used the same IV on the left arm on 1/16/24 because it put Resident 258 at risk for discomfort and infection. A review of Resident 258's Care Plan, initiated on 1/11/24, indicated the resident is at risk for infection related to the resident having an IV catheter. The care plan also indicated to re-site IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 9 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 per IV Therapy Protocol. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, General Policies for IV Therapy, dated June 2018, indicated an IV site must be replaced at least every 96 hours. It also indicated that a physician's order is required to extend the use of an IV site beyond 96 hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 10 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 160) for dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care area, who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services in accordance with the facility policy. This deficient practice had the potential for Resident 160 to suffer from complications such as bleeding or infection from the central venous catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein. Findings: A review of Resident 160's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis, and hypertension (high blood pressure). A review of Resident 160's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/2/24, indicated Resident 160's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 160 required partial assistance (helper does more than half the effort) with eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene. It also indicated that Resident 160 was dependent with shower, lower body dressing and putting on/taking off footwear. A review of Resident 160's order summary report, dated 1/19/24, indicated an order on 12/29/23 to monitor dialysis site, right upper chest tunnel catheter (a flexible catheter [thin tube] that goes into a vein in your chest) for tenderness, redness or bleeding every shift, document findings outside of baseline and call MD. During a concurrent record review of Resident 160's Dialysis Communication Record and interview on 1/19/24 at 11:26 AM with Licensed Vocational Nurse 1 (LVN1), LVN 1 verified Resident 160's Dialysis Communication Record was not filled out completely on 1/18/24. The post dialysis assessment form indicated dialysis access location of right upper chest catheter/central line, bruit (a sound created when blood flows through a narrowed space) and thrill (vibration caused by blood flow) are present. The post dialysis assessment form which included the vital signs, name of Resident, Physician, room number were not completed on 1/18/24. LVN 1 stated the Dialysis Communication Record for Resident 160 should have been completed by the Charge Nurse upon Resident's return from dialysis to know the status of the resident. LVN 1 stated that Resident 160 has a right upper chest central line. Therefore, a presence of bruit and thrill was a wrong assessment because bruit and thrill can only be assessed from a dialysis arteriovenous (AV) fistula (vascular access in patients receiving regular hemodialysis) access and not from a central line. During a concurrent record review of Resident 160's Dialysis Communication Record, dated, 1/13/24, 1/15/24, 1/16/24, and 1/18/24, and interview on 1/19/24 at 7 PM with the Director of Nursing (DON), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 11 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the DON stated Resident 160 had a right upper chest central dialysis access site. The DON verified that Resident 160's dialysis communication record on 1/18/24 was incomplete because it did not include Resident 160's name, physician, and room number. The DON also stated the assessment was inaccurate due to the incorrect Resident 160's dialysis access site documented. The DON stated since Resident 160 has a right upper chest central line, the check mark on the Dialysis Communication Record for presence of bruit and thrill was a wrong assessment. The DON also confirmed that Resident 160's Dialysis communication record on 1/13/24 was incomplete as evidence by having a blank (not filled) primary hemodialysis nurse. The DON stated that there should have been a signature next to primary hemodialysis nurse and it should have been completed in the dialysis center. The DON stated the receiving LVN or RN should have called the dialysis center if Dialysis communication record was incomplete. The DON stated, it was important to properly assess residents, document accurately, and complete the Dialysis communication record to make sure that resident will receive the proper care. The DON added that Charge nurses need to check vital signs and the resident's dialysis access needs to be observed and documented. A review of the facility's policy and procedure titled, Renal Dialysis, Care of Residents, revised December 2013, indicated Dialysis Resident's Care Documentation to record date, time, access site conditions, patency after dialysis and access site care in the Dialysis Communication Form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 12 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to ensure there was a Registered Nurse (RN) on duty for at least eight (8) consecutive hours on 10/1/23, 11/12/23 and 12/10/23 to ensure all the residents' clinical needs were met either directly by the RN or indirectly by the Licensed Vocational Nurses (LVNs) or Certified Nurse Assistants (CNAs) for whom the RN was responsible for overseeing resident care. This deficient practice had the potential for delay in care and services and have the potential for harm to residents. Findings: A review of Payroll Based Journal (PBJ, a system for facilities to submit staffing information) Staffing Report, dated 1/10/24, indicated there were RN hours triggered (requires follow-up during the survey) on 10/1/23 to 12/31/23. During a concurrent review of the Facility's Report of Hours Worked Summary for the month of October 2023 to December 2023, and interview with Administrator (ADMIN) and Business Office Assistant (BOA) on 01/19/24 at 9 AM, BOA verified that on 10/1/23, 11/12/23 and 12/10/23, the requirement to have an RN for 8 hours was not met. ADMIN stated that Director of Nursing (DON) has been filling in the RN hours on the days that there was no RN. ADMIN stated that he was aware that there were days that DON can only fulfill four (4) RN hours and not the required 8 RN hours. During an interview with the DON on 01/19/24 at 7:20 PM, the DON stated that she would sometimes come to work for 4 hours on the day when an RN was not scheduled. The DON stated that she was aware of the required 8 RN hours, and she stated that they did not meet the requirements on 10/1/23, 11/12/23 and 12/10/23. The DON stated that it was important to have an RN for 8 consecutive hours in the facility each day because there were tasks that only an RN can do. The DON stated RN duties like resident's assessment, admission, and administration of intravenous (IV) therapy (IV therapy, is a medical technique that administers fluids, medications and nutrients directly into a person's vein). A review of the Facility Assessment, dated January 2024, indicated the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. A review of Facility's undated Registered Nurse Supervisor job description, indicated the position is to supervise the day-to-day activities of the facility during shift in accordance with current federal, state, and local standards that govern the facility, and as directed by your management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 13 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to: Residents Affected - Some 1. Administer medications timely to one (1) of four (4) residents (Resident 158) observed for medication administration. This deficient practice had the potential for Resident 158's health and well-being to be negatively impacted. 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication [CM] or Controlled Substance [CS, medications which have a potential for abuse and may also lead to physical or psychological dependence]) accountability logs for November 2023, December 2023, and January 2024. This deficient practice resulted in not following the facility's Controlled Medication Disposal Policy and Procedure (P&P) on the control and accountability of CS's awaiting final disposition (process of returning and/or destroying unused medications). This deficient practice also increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and accidental exposure of Residents to harmful medications. Findings: 1. During a review of Resident 158's admission Record (a document containing demographic and diagnostic information), indicated Resident 158 was originally admitted to the facility on [DATE] with diagnosis, including but not limited to arthritis (a disease of inflammation of the joints causing stiffness and pain), Parkinson's disease (a disease that affects the body's nervous system), benign prostatic hyperplasia (BPH, a condition in men where the prostate gland [a small gland located inside the groin] is enlarged), bipolar disorder (a mental health condition that causes extreme mood swings), depression (an illness that negatively affects how the residents feel and act). During a review of Resident 158's (Medication Administration Record (MAR, a record of mediations administered to residents), for January 2024, the MAR indicated Resident 158 was prescribed the following medications: 1. Docusate 100 milligram (mg, unit of measure of mass) 1 tablet by mouth to be given once a day as stool softener at 9 AM 2. Finasteride 5 mg 1 tablet by mouth to be given once a day for BPH at 9 AM 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 14 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0755 Magnesium oxide 400 mg 1 tablet by mouth to be given once a day as supplement at 9 AM Level of Harm - Minimal harm or potential for actual harm 4. Multivitamin with minerals 1 tablet by mouth to be given once a day as supplement at 9 AM Residents Affected - Some 5. Venlafaxine Extended Release (ER, drug is released slowly over time) 75 mg 1 capsule by mouth to be given once a day for Depression at 9 AM 6. Vitamin D3 1000 international units (IU, unit of measure of mass) 1 tablet by mouth to be given once a day as supplement at 9 AM 7. Calcium 600 mg with Vitamin D3 400 IU 1 tablet by mouth to be given twice a day as supplement at 9 AM and 5 PM 8. Divalproex DR 125 mg 1 tablet by mouth to be given twice a day for Bipolar disorder at 9 AM and 5 PM 9. Eliquis 5 mg 1 tablet by mouth to be given twice a day for blood clot prevention at 9 AM and 5 PM 10. Megace (400 mg/10 ml) 10 ml by mouth to be given twice a day for appetite stimulant at 9 AM and 5 PM 11. Vitamin C 500 mg 1 tablet by mouth to be given twice a day as supplement at 9 AM and 5 PM 12. Pramipexole 0.25 mg 1 tablet by mouth to be given three times a day for Parkinson's disease at 9 AM, 1 PM, and 5 PM 13. Diclofenac 1% gel 4 gm applied to left shoulder four times a day for pain management at 9 AM, 1 PM, 5 PM, and 9 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 15 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0755 14. Level of Harm - Minimal harm or potential for actual harm Lactulose (20 mg/30 ml) 30 ml by mouth to be given four times a day for bowel management at 9 AM, 1 PM, 5 PM, and 9 PM Residents Affected - Some During an observation on 1/17/24 at 11:08 AM, LVN 1 was observed administering the following medications to Resident 158. 1. Docusate 100 milligram oral tablet 2. Finasteride 5 mg oral tablet 3. Magnesium oxide 400 mg oral tablet 4. Multivitamin with minerals oral tablet 5. Venlafaxine ER 75 mg oral capsule 6. Vitamin D3 1000 IU oral tablet 7. Calcium 600 mg with Vitamin D3 400 IU oral tablet 8. Divalproex DR 125 mg oral tablet 9. Eliquis 5 mg oral tablet 10. Megace (400 mg/10 ml) 10 ml oral suspension 11. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 16 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0755 Vitamin C 500 mg oral tablet Level of Harm - Minimal harm or potential for actual harm 12. Pramipexole 0.25 mg oral tablet Residents Affected - Some 13. Diclofenac 1% topical gel 14. Lactulose (20 mg/30 ml) 30 ml oral solution Resident 158 was observed swallowing the oral medications with a full glass of water. During an interview on 1/17/24 at 11:01 AM, with LVN 1, LVN 1 stated LVN 1 administered the 9 AM medications for Resident 158 late on 1/17/23 at 11:08 AM. LVN 1 stated per facility policy, medications should be administered up to one hour before or one hour after the scheduled time. LVN 1 stated that LVN 1 was late in administering the medications that morning because LVN 1 was interrupted with other tasks during medication administration. During an interview on 1/17/24 at 11:17 AM, with the Director of Nursing (DON), the DON stated medication administration should be done between 8 AM and 10 AM, for the 9 AM scheduled medications. The DON stated administering medications late goes against facility policy. During an interview on 1/17/24 at 12:17 PM, with the DON, the DON stated that LVN 1 was distracted by family members and facility staff interrupting the 9 AM medication administration on 01/17/24 for Resident 158. The DON stated that while administering medications, LVN's should focus on medication administration and be free from interruptions. The DON stated that LVN 1 failed to follow policy of administering 9 AM medications on time for Resident 158 on 1/17/24. During a review of the policy and procedures (P&P) titled, Medication Administration - General Guidelines, dated October 2017, the P&P indicated The facility has sufficient staff to allow for administering of medications without unnecessary interruptions. It also indicated Medications are administered without unnecessary interruptions and Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after). 2. During a concurrent record review on 1/18/24 at 1:31 PM, with the Director of Nursing (DON), the Antibiotic or Controlled Drug Record accountability logs for November, December 2023 and January 2024 for CS's awaiting final disposition did not contain any verifying signatures. During a concurrent interview, the DON stated was unable to locate the verifying signatures of LVNs and RN or DON on the November 2023, December 2023, and January 2024 accountability logs. The DON stated the DON counts the CS's with the LVNs upon receipt of the accountability logs, however there was no process for the LVNs or DON to sign the logs. The DON stated understands the importance of CS accountability by verifying and signing the logs to ensure each CS was accounted for until disposed, and to prevent diversions and accidental exposure of harmful substances to residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 17 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the P&P titled, Controlled Medication Disposal, dated January 2013, the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. A. The DON and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. B. When a dose of a CM is removed .It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of CS wasted for any reason. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 18 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that its medication error rate was less than five (5)percent (%). Two (2) medication errors out of 37 total opportunities contributed to an overall medication error rate of 5.41% affecting 2 of four (4) residents observed for medication administration (Resident 44 and 110.) The medication errors were as follows: Residents Affected - Some 1. Resident 44 did not receive a dose of calcium with vitamin D3 (a combination medication used as a dietary supplement to provide support to bones) as indicated on the Physician's order. 2. Resident 110 was to be administered potassium chloride (a medication used to prevent low amounts of potassium in the blood) against Resident 110's physician orders. These failures had the potential to result in Resident 44 and 110 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 44's and 110's health and well-being to be negatively impacted. Findings: 1. During a review of Resident 44's Face Sheet (FS, a document containing demographic and diagnostic information), the FS indicated the resident was originally admitted to the facility on [DATE] with diagnoses including osteoporosis (a condition in which the bones become brittle and fragile, typically as a result of deficiency of calcium or vitamin D.) During a review of Resident 44's Order Summary Report, for January 2024, indicated Resident 44 was prescribed Calcium + D3 Oral Tablet 600-20 milligram (mg, a unit of measure of mass) - microgram (mcg, a unit of measure of mass) to be given by mouth once a day, starting 11/18/23. The clinical record contained no documentation that the resident should be given a dose of calcium 600 mg with vitamin D3 5 mcg. During a review of Resident 44's Medication Administration Record (MAR) for January 2024, the MAR indicated Resident 44 was prescribed Calcium + D3 Oral Tablet 600-20 mg-mcg to be given by mouth once a day, at 9 AM. During an observation on 1/16/24 at 9:23 AM, in medication cart 2, licensed vocational nurse (LVN) 2 was observed administering calcium 600 mg with vitamin D3 5 mcg tablet to Resident 44. Resident 44 was observed swallowing the calcium 600 mg with Vitamin D3 5 mcg tablet with full glass of water. During an interview on 1/16/24 at 12:39 PM, with LVN 2, LVN 2 stated that LVN 2 administered calcium 600 mg with vitamin D3 5 mcg tablet to Resident 44 during the morning medication administration on 1/16/24 at 9:23 AM. LVN 2 stated that LVN 2 failed to clarify the medication order as the dose of vitamin D3 was unclear to LVN 2. LVN 2 stated that LVN 2 administered the wrong dose of vitamin D3 based on the physician order. During an interview on 1/17/24 at 9:47 AM, with Nurse Practitioner (NP), NP stated vitamin D3 should have a dose and measure of unit assigned to the order, and the order for Resident 44 was to give calcium 600 mg with vitamin D3 5 mcg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 19 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0759 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/17/24 at 12:17 PM, with Director of Nursing (DON), the DON stated the medication order for calcium with vitamin D3 for Resident 44 as transcribed (written or copied) on the Medication Administration Record (MAR, a record of medications administered to residents) was unclear and confusing, and did not indicate to administer a dose of vitamin D3 5mcg. The DON stated that the order for calcium with vitamin D3 needed to be clarified to ensure the dose and units for Vitamin D3 were clear. Residents Affected - Some During an interview on 1/19/24 at 10:52 AM, with DON, the DON stated that LVN 2 should follow medication administration guidelines to ensure physician orders were followed and the right medication and dose were administered to residents. The DON stated the specific physician order for vitamin D3 ensures Resident 44 maintains a level of vitamin D that is adequate for bone strength. The DON stated administering a subtherapeutic (less than an amount to produce an effect) dose of vitamin D3 may harm the resident. The DON stated LVN 2 failed to clarify and follow physician's order and administered the wrong dose of calcium with vitamin D3 to Resident 44. 2. During a review of Resident 110's FS, the FS indicated the resident was originally admitted to the facility on [DATE] with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure.) During a review of Resident 110's Order Summary Report for January 2024, indicated Resident 110 was prescribed Lasix 40 mg 1 tablet to be given by mouth once a day for hypertension and to hold the dose if SBP less than 110, starting 12/27/23, and was prescribed potassium chloride 10 meq 1 tablet to be given once a day for concurrent use with Lasix, starting 1/11/24. The clinical record contained no documentation that the resident should be given a dose of potassium chloride 10 meq without the use of Lasix. During a review of Resident 110's MAR for January 2024, the MAR indicated Resident 110 was prescribed Lasix 40 mg 1 tablet to be given by mouth once a day for hypertension and to hold the dose of SBP less than 110, and potassium chloride 10 meq 1 tablet to be given once a day for concurrent use with Lasix, at 09:00 AM. During an observation on 1/17/24 at 10:25 AM, in medication cart 3, LVN 2 was observed not administering Lasix (a medication used to eliminate excess fluid from the body, which can also lead to the elimination of potassium [an electrolyte that is critical for maintaining regular heartbeat]) 40 mg tablet to Resident 110. LVN 2 was observed handing Resident 110 potassium chloride 10 milliequivalent (meq, unit of measure of mass) tablet that LVN 2 had prepared for administration. During an interview on 1/17/24 at 12:29 PM, with LVN 2, LVN 2 stated that Resident 110's order for potassium chloride should be given concurrently (at the same time) with Lasix, according to the physician order. LVN 2 stated that LVN 2 did not administer Lasix to Resident 110 since the resident's systolic blood pressure (SBP, measure of pressure in arteries [a vessel that carries blood away from the heart] during heart beats) was 108 millimeters of mercury (mmHg, unit of measure of blood pressure,) during the morning medication administration on 1/17/24 at 10:25 AM. LVN 2 stated that LVN 2 failed to offer the administration of potassium chloride to Resident 110, since Resident 110 was not administered Lasix. LVN 2 stated that Lasix clears potassium from the body therefore potassium supplementation is needed. LVN 2 stated when not administering Lasix, potassium does not clear from the body therefore potassium supplementation is not needed. During an interview on 1/19/24 at 10:52 AM, with DON, the DON stated when not administering Lasix (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 20 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0759 Level of Harm - Minimal harm or potential for actual harm to Resident 110, potassium chloride should not be administered according to the physician orders. The DON stated that Lasix eliminates potassium from the body, and administering potassium chloride without administering Lasix can cause the body to have excessive amounts of potassium. The DON stated that high levels of potassium can have negative affects to the heart and harm Resident 110 by causing cardiac arrest (sudden loss of heart function, breathing and consciousness.) Residents Affected - Some During a review of the facility's policy and procedures (P&P) titled, Medication Administration - General Guidelines, dated October 2017, the P&P indicated to: A. Preparation 3. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. B. Administration 2. Medications are administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 21 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Remove and discard one expired insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial for Resident 17, and one expired inhalation solution for Resident 48, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South Station 4.) 2. Label one inhalation treatment with an open date for Resident 36, in accordance with facility requirements in one of two inspected medication carts (Medication Cart South Station 4.) 3. Store one insulin Humulin R vial for Resident 209 and one insulin Lantus (long-acting insulin) Solostar pen (type of insulin injection devise) for Resident 259, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South Station 4.) These practices increased the risk for Residents 17, 36, 48, 209, and 259 to have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 11:15 AM, in Medication Cart South Station 4, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies: 1.a. One open insulin Humulin R vial for Resident 17 was found stored at room temperature with a label indicating that storage at room temperature began on [DATE]. A review of the manufacturer's product labeling indicated opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening or once storage at room temperature began. 1.b. One open Atrovent (medication used for shortness of breath) inhalation (a form of a medication to be inhaled as a vapor or spray) aerosol for Resident 36 was found stored at room temperature without a label indicating when storage or use at room temperature began. A review of the facility policy and procedure indicated opened multi-use medications should be labeled with a date indicating when use began. 2. One open Albuterol (medication used to prevent and treat difficulty in breathing, shortness of breath, and coughing) inhalation solution foil pack for Resident 48 was found stored at room temperature and not labeled with a date on which foil pack was opened. Pharmacy fill date for the pack was labeled as [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 22 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the manufacturer's product storage and labeling indicated opened foil packs of albuterol inhalation solutions should be stored at room temperature between 36 to 77 degrees Fahrenheit and used or discarded within 30 days. 3.a. One unopened insulin Humulin R vial for Resident 209 was found stored at room temperature without a label indicating when storage or use at room temperature began. A review of the manufacturer's product labeling indicated opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening or once storage at room temperature began. 3.b. One open insulin Lantus Solostar pen for Resident 259 was found stored at room temperature without a label indicating when storage or use at room temperature began. A review of the manufacturer's product labeling indicated open Lantus Solostar insulin pens should be stored should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening or once they've been stored at room temperature. During a concurrent interview with LVN 3, LVN 3 stated that the Humulin R insulin vial for Resident 17 expired on [DATE] and should be removed from the medication cart, the Humulin R vial for Resident 209 and the Lantus pen for Resident 259 was not labeled with a date when use at room temperature began and therefore it is unknown when they expire and need to be discarded. LVN 3 stated all three insulins need to be replaced from pharmacy to ensure expired insulin is not used in error for Residents 17, 209 and 259. LVN 3 stated administering expired insulin will not be effective in keeping the blood sugar stable and can harm Resident 17, 209 and 259 by causing high or low blood sugar levels. During the same interview, LVN 3 stated the Atrovent inhalation for Resident 36 was not labeled with a date when opened, and the Albuterol inhalation for Resident 48 was not labeled with a date when the foil pack was opened. LVN 3 stated per facility policy the inhalations should be labeled with the date when first opened to know when they expire. LVN 3 stated not knowing when the inhalations expire can potentially lead to the administration of ineffective medication to Resident 36 and 38, and cause harm by not treating the shortness of breath leading to stoppage of breathing. During an interview on [DATE] at 10:52 AM, with Director of Nursing (DON), the DON stated that the insulin Humulin R vial for Resident 17 was expired and should be removed from the medication cart, the unopened insulin Humulin R vial for Resident 209 should be stored in the refrigerator or labeled with a date when it came to storage at room temperate, and the open insulin Lantus pen for Resident 259 should be labeled with a date when it came to use at room temperature to know when it expires. The DON stated insulins without a label indicating the date of use or storage at room temperate are considered expired, should not be used, and removed from medication carts. The DON stated several LVN's failed to label insulins with a date open label and failed to remove expired insulins from the medication cart, which can potentially lead to the administration of expired insulin to residents leading to medication errors. The DON stated administering expired insulin to residents will not be effective in controlling the blood sugar levels and lead to hospitalization. During the same interview, the DON stated the foil pouch covering the Albuterol prevents the medication from degradation (decline in quality) and decrease in potency (effectiveness) from light exposure, and once the foil pouch is open and exposed to light, the inhalation solution is good for 30 days. The DON stated the Albuterol for Resident 48 is considered expired and that the resident may have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 23 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0761 Level of Harm - Minimal harm or potential for actual harm received expired doses. The DON stated receiving expired Albuterol can harm Resident 48 by not effectively treating the SOB potentially leading to hospitalization. A review of the facility's policy and procedures (P&P) titled, Procedures for All Medications, dated [DATE], the P&P indicated to: Residents Affected - Some E. Check the expiration date on package/container. When opening a multi-dose container, place the date on the container. A review of facility's P&P titled, Storage of Medications, dated [DATE], indicated that Medications and biologicals are stored safely, and properly, following manufacturer's recommendations or those of the supplier. M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. A review of facility's P&P titled, Vials and Ampules of Injectable Medications, dated [DATE], indicated that Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials. F. Medication in multi-dose vials may be used until the manufacturer's expiration date or 6 months after opening unless otherwise specified. Refer to Guide for Special Handling of Medications. A review of facility's undated P&P titled, Guide for Special Handling of Medications, indicated the following: Insulin products - store unopened vials in the refrigerator. May store opened vials at room temperature or in the refrigerator. Discard 28 days after opening or removed from refrigeration. Insulin pens and cartridges - store at room temperature and do not refrigerate after opening. Expiration dates vary by manufacturer. A review of facility's P&P titled, Discontinued Medications, dated [DATE], the P&P indicated that When medication are expired, discontinued by a prescriber .the medications are marked as discontinued or stored in a separate location and later destroyed. A. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. The date the medication was discontinued shall be indicated on the medication container. B. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt of an order to discontinue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 24 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prevent food contamination and the spread of foodborne illness as indicated on the facility policy when: Residents Affected - Some 1. Used bottles of juice and water were found on top of the bucket that contains the dishwasher's cleaning solution. 2. A broiler and a fan that are used to airdry clean dishes were found to have dust. The broiler and fan were not on the cleaning schedule log. These deficient practices had the potential to increase the risk of food contamination and the spread of foodborne illness to the residents. Findings: 1. During an observation and concurrent interview on 1/16/24 at 8:25 AM, of the kitchen's dishwashing station, with Food and Nutrition Services Aide (DA), the following were observed on top of the bucket that contains the cleaning solution for the dishwasher: a. a used bottle with red liquid b. a used bottle with clear liquid c. an empty soda can DA stated the bottles and soda can should not be on top of the bucket that contains the cleaning solution for the dishwasher because of the risk of contaminating the cleaning solution. DA stated the residents could get sick. During an interview on 1/18/24 at 1:39 PM with Registered Nurse 1 (RN 1), RN 1 stated the water pitchers on the medication carts are used by the nurses to administer medications to all the residents. RN stated if the water pitchers are contaminated, residents could get sick from drinking the water from the pitchers. During an interview on 1/16/24 at 2:55 PM with Dietary Supervisor (DS), DS stated all the dishes that the residents use to eat and the water pitchers that nurses use to give medications are cleaned using the dishwasher. DS stated the top of the bucket of the dishwasher's cleaning solution is considered a work surface and must be free from potential contaminants to avoid cross contamination. DS further stated residents could get sick from foodborne illness if the solution gets contaminated. During an interview on 1/18/24 at 1:46 PM with Infection Preventionist Nurse (IPN), IPN stated if the cleaning agent get contaminated, the dishes and water pitchers could become contaminated. IPN also stated if the dishes become contaminated, the residents could get sick. During a review of the facility's DA job responsibilities, revised 2/04/20, it indicated DA must follow proper sanitization and cleaning methods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 25 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Food Preparation, revised 2/04/20, the P&P indicated to properly sanitize work surfaces to avoid cross contamination. 2. During an observation and concurrent interview with DS on 1/16/24 at 12:08 PM, of the kitchen's dishwashing station and broiler, the broiler and fan that dries the clean dishes and water pitchers used by nurses to give medications have thick dust. DS stated the dust can potentially contaminate the resident's foods and water. DS stated residents can get foodborne illness if dust gets to the residents' food. During a concurrent interview and record review on 1/16/24 at 2:55 PM, of the kitchen's cleaning schedule logs titled, Daily Cleaning Log and Weekly Cleaning Schedule, with DS, DS stated the fan is not part of the kitchen's current logs. DS added the fan should be in the cleaning schedule logs because it is considered a work surface. DS also indicated the broiler should be cleaned because it is part of the oven. During an interview on 1/18/24 at 1:46 PM with Infection Preventionist Nurse (IPN), IPN stated if dust got into the clean dishes and water pitchers, the residents could potentially get sick. During an interview on 1/19/24 at 3:53 PM with Director of Nursing (DON), DON stated if the dishes and food become contaminated, any or all the facility's residents can get sick. During a review of the facility's P&P titled, Safety and Sanitation, revised 2/04/20, the P&P indicated stove tops, ovens, and hoods must be routinely cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 26 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 maintain accurate medical records for one (Resident 49) of 18 residents when Resident 49's three vaccination (vaccines, medication given to provide protection from certain diseases) declination forms were not completed. This failure had the potential to put Resident 49 at risk for missing future opportunities to be vaccinated. Findings: During a review of Resident 49's admission Record indicated the resident was admitted to the facility on [DATE] with admitting diagnoses of myocardial infarction (heart attack), hypertension (abnormally high blood pressure, even at rest), and history of falling. During a concurrent interview and record review of Resident 49's medical record on 1/18/24 at 11:25 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 49 declined the Pneumococcal (inflammation of the lungs due to an infection), Respiratory Syncytial Virus (RSV, infection of the lungs and respiratory tract caused by a virus), and COVID-19 (infectious disease caused by the SARS-CoV-2 virus) vaccines. RN 1 stated the forms in Resident 49's medical records titled, Pneumococcal Vaccination Consent Form, RSV (Respiratory Syncytial Virus) Vaccine Consent Form, and 2023-2024 COVID-19 Vaccine Declination Form, were incomplete because: 1. The RSV (Respiratory Syncytial Virus) Vaccine Consent Form contained a signature but did not have an entry for Resident name and date. 2. The Pneumococcal Vaccination Consent Form contained a signature but not contain an entry for Resident name and date. 3. The 2023-2024 COVID-19 Vaccine Declination Form contained Resident 49's name and signature but did not indicate the date when the form was signed. During an interview on 1/19/24 at 1:23 PM with Infection Preventionist Nurse (IPN), IPN stated having the date on the declination forms is important because without the dates, nurses won't know when to offer the vaccines again. IPN stated residents can retract their declination of vaccines and may choose to take the vaccines at a later time after initially declining. During an interview and concurrent record review on 1/19/24 at 3:52 PM with Director of Nursing (DON), DON stated the facility's policy titled, Charting and Documentation, revised July 2017, indicated documents in the residents' medical records must be complete and accurate and must include the date and time the procedure/treatment was provided. DON stated if the forms are not complete, the resident could potentially miss out on being offered the vaccines. A review of the facility's policy titled, Vaccination of Residents, revised October 2019, indicated the refusal of vaccines shall be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 27 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 Based on observation and interview, the facility failed to ensure infection control procedures were maintained for two (2) of 2 sampled residents (Residents 158 and 19) for infection control care area, as indicated in the facility policy by failing to ensure: Residents Affected - Some 1. reusable medication bubble packs (medication packaging system that contains individual doses of medication per bubble) and multi-use medication bottles were disinfected (cleaning with a solution that destroys organisms) during medication administration for Resident 158. This deficient practice increased the risk for Resident 158 and all Residents utilizing medications from Medication Cart 1 to be exposed to infective pathogens (a bacteria, virus or other organism that can cause disease) that were transferred from Resident 158's room to Medication Cart 1 to subsequent residents, resulting in possible active infections (organisms causing disease that is rapidly reproducing.) 2. Certified Nurse Assistant 2 (CNA 2) perform handwashing after touching the toilet seat and proceeding to Resident 19 to fix the resident's nasal cannula (a device used to deliver supplemental oxygen [colorless, odorless, and tasteless gas]). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: 1. During an observation on 1/17/24 at 11:08 AM, Licensed Vocational Nurse (LVN) 1 was observed taking the following medication bubble packs and multi-use medication bottles from Medication Cart 1 inside Resident 158's room and placing them on a table near the resident's bed: a. Calcium 600 milligram ([mg]-unit of measure of mass) with vitamin D 400 international units ([IU] - unit of measure of mass) bottle b. Magnesium oxide 400 mg bottle c. Multivitamin with mineral bottle d. Vitamin C 500 mg bottle e. Docusate 100 mg bottle f. Vitamin D3 1000 IU bottle g. Eliquis 5 mg bubble pack h. Finesteride 5 mg bubble pack i. Divalproex Delayed Release 125 mg bubble pack j. Pramipexole 0.25 mg bubble pack (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 28 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 k. Venlafaxine Extended Release 75mg bubble pack Level of Harm - Minimal harm or potential for actual harm LVN 1 was observed identifying each medication against the medication bubble pack and bottles on the table to provide the name and use of each medication to Resident 158, one at a time prior to administration. Resident 158 was observed swallowing the medications with full glass of water. LVN 1 was then observed taking the medication bubble packs and multi-use bottles from the table in Resident 158's room and placing them in Medication Cart 1. Residents Affected - Some During a concurrent interview with LVN 1, LVN 1 stated that the medication bubble packs and multi-use medication bottles should remain in the medication cart and bringing them inside Resident 158's room and back in the Medication Cart 1 without disinfecting them is an infection control issue. During an interview with the Director of Nursing (DON) on 1/17/24 at 11:08 AM, the DON stated taking medication bubble packs and multi-use medication bottles inside Resident 158's room and back in the Medication Cart 1 without disinfecting them is an infection control issue. During an interview with Infection Preventionist Nurse (IPN) on 1/19/24 at 10:04 AM, the IPN stated reusable items such as medication bubble packs and multi-use medication bottles should be disinfected prior to taking inside resident's room and disinfected after taking out of resident's room prior to placing them back in medication carts to prevent possible infections. During an interview with the DON on 1/19/24 at 10:52 AM, the DON stated not disinfecting medication bubble packs and multi-use medication bottles prior to placing on a table inside resident's room, and not disinfecting after bringing them out of the resident's room is considered an infection control issue. A review of the facility's policy and procedures (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, indicated Resident-Care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. 5. Reusable items are cleaned and disinfected or sterilized between residents. 6. Reusable resident care equipment is decontaminated and/or sterilized between residents . 7. Only equipment that is designated reusable is used by more than one resident. 2. A review of Resident 19's admission Record indicated the facility admitted Resident 19 on 12/19/22 with diagnoses including history of falling, difficulty of walking, and lack of coordination. A review of Resident 19's Minimum Data Set (MDS, standardized care and screening tool), dated 12/25/23, indicated Resident 19 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on toileting hygiene, shower / bathe self, and personal hygiene. A review of Resident 19's Order Summary report, dated 10/30/23, indicated oxygen at 2 liters via nasal cannula continuously. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 29 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 Residents Affected - Some During an observation on 1/17/24 at 7:05 AM, Certified Nursing Assistant (CNA 2) was observed touching the toilet seat and proceeded to Resident 19 to fix the resident's nasal cannula without performing handwashing. During interview on 1/17/24 at 12:33 PM, CNA 2 stated washing hands was important to prevent infection control. CNA 2 further stated handwashing should be done before and after resident contact and she should have washed her hands after touching the toilet seat and before assisting Resident 19 with her nasal cannula. During interview on 1/19/24 at 11:22 AM, with the infection preventionist nurse (IPN), IPN stated hand washing was enforced to prevent spread of infection. The IPN also stated, hand washing should be done before and after each resident's care and when hands are visibly soiled. During a review of facility's policies and procedure (P&P) titled, Handwashing / Hand Hygiene, revised 10/2019 indicated under policy statement, This facility considers hand hygiene the primary means to prevent the spread of infections. The P&P also indicated, all personnels shall be trained and regularly in-serviced on the importance of hand hygiene in preventing transmission of healthcare associated infections. The P&P also indicated, all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to the other personnel, resident, and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 30 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 0911 Level of Harm - Potential for minimal harm Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Based on observation, interview and record review, the facility failed to ensure one (1) of 24 rooms (Room O) accommodated no more than four residents in each room. Room O have four residents and five beds. Residents Affected - Some This deficient practice has the potential for the resident's care and services to not be adequately accommodated, have an adverse effect on the residents' safety, affect provision of care and services, and place residents at risk for lack of privacy. Findings: During an observation of Room O on 01/16/24 from 8:50 AM, observed Room O with five beds in a room. In Room O, all five beds were observed to be occupied. A review of the room waiver, dated 01/16/24, indicated the following: Room #Beds square foot (sq. ft, unit of measurement). O 5 511.60 During a concurrent review of the facility's client accommodation analysis and interview with the Administrator (ADMIN) on 01/16/24 at 10 AM, the ADMIN stated the facility have 24 resident's rooms. The ADMIN stated Room O has 5 beds and 4 residents. The ADMIN stated he will continue to request for room waiver because it did not affect the health and safety of the residents. The ADMIN stated there was enough space for the staff to provide care to the residents. A review of the facility's room waiver letter, dated 1/16/24, indicated a request for the continued waiver for square footage per resident; in the condition that room assignments are reviewed during the admission process and checked frequently for appropriateness. Ample space is provided for resident care and mobility, allowing the facility to meet resident's needs without adversely affecting resident's health and welfare. Room rounds are also conducted to ensure there are no unnecessary items or equipment maintained in stored in the rooms that prevent access. The Department recommends the room waiver for Room O. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 31 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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. Based on observation, interview and record review, the facility failed to provide the minimum of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident bedrooms for 14 of 24 residents' rooms in the facility, unless granted a room waiver by the Centers for Medicare and Medicaid services (CMS). This deficient practice had the potential to affect the ability to provide a home like environment to the residents. Findings: During a tour of the facility on 01/16/24 at 8:30 AM, 14 of 24 residents' rooms did not meet the minimum 80 sq. ft. per resident in multiple resident bedrooms. These are rooms A, B, C, D, E, F, G, H, I, J, K, L, M, and N. The residents did not complain regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. Residents that are wheelchair bound were able to move in the room without difficulty. During a concurrent review of the facility's client accommodation analysis and interview with the Administrator (ADMIN) on 01/16/24 at 10 AM, the ADMIN stated the facility have 24 resident rooms. The ADMIN stated 14 rooms does not met the 80 square feet per resident in multiple resident bedrooms. The ADMIN stated he will continue to request for room waiver because it did not affect the health and safety of the residents. The ADMIN stated there was enough space for the staff to provide care to the residents. A review of the facility's Client Accommodation Analysis form, dated 1/16/24, indicated the actual square footage of Resident rooms A, B, C, D, E, F, G, H, I, J, K, L, M, and N not meeting the required room size as followed: Room #Beds Sq.Ft. Sq.Ft. per Bed A 2 156.51 78.25 B 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 32 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 159.33 Level of Harm - Potential for minimal harm 79.66 C Residents Affected - Some 2 156.51 78.25 D 2 159.04 79.52 E 2 155.40 77.70 F 2 155.40 77.70 G 2 155.40 77.70 H 2 157.62 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 33 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 78.81 Level of Harm - Potential for minimal harm I 2 Residents Affected - Some 155.40 77.70 J 2 158.20 79.10 K 2 155.40 77.70 L 2 155.40 77.70 M 2 159.33 79.66 N 2 159.33 79.66 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 34 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 A review of the facility's room waiver letter, dated 1/16/24, indicated a request for the continued waiver for square footage per resident; in the condition that room assignments are reviewed during the admission process and checked frequently for appropriateness. Ample space is provided for resident care and mobility, allowing the facility to meet resident's needs without adversely affecting resident's health and welfare. Room rounds are also conducted to ensure there are no unnecessary items or equipment maintained in stored in the rooms that prevent access. During the survey from 01/16/24 to 01/19/24, the following was observed, for the rooms A, B, C, D, E, F, G, H, I, J, K, L, M, and N, there was adequate ventilation and lighting. The residents in the rooms had bathroom and toilet facilities. The residents had privacy curtains around their beds, and which assured privacy. There was adequate space for getting in and out of the wheelchairs and residents were afforded sufficient freedom of movement in the rooms. The Department would be recommending the room waiver for rooms A, B, C, D, E, F, G, H, I, J, K, L, M, and N. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 35 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 the facility failed to maintain safe, clean, comfortable sanitary and home like environment for four of five sample residents (Resident 24, 19, 38 and 3) for environment care area by failing to ensure: 1. Resident 24's gastrostomy tube (G-tube, tube inserted through the belly that brings nutrition directly to the stomach) pump was clean free of dry milk brownish in color. 2. The toilet seat cover screw in Room A's bathroom was not sticking out. 3. The side drawers in Room C did not have peeled off and missing vinyl panels leaving an exposed brown wood with sharp edges. 4. The toilet seat in Room B's bathroom was free of dry brown fecal matter and used toilet paper on the floor. 5. The hallway was free from clutter such as the shower chair with dirty bucket with dry brownish black stuff on it. These deficient practices caused an unsanitary environment and had a potential for residents to be placed at risk for injury. Findings: 1. A review of Resident 24's admission Record indicated the facility admitted Resident 24 on 10/23/24 with diagnosis which include anxiety (persistent and excessive worry that interferes with daily activities), lack of coordination, aphasia (language disorder that affects a person's ability to communicate) and gastrostomy status (presence of gastrostomy [artificial opening to stomach] present on admission). A review of Resident 24's Minimum Data Set (MDS, standardized care and screening tool), dated 01/8/23, indicated Resident 24 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 24 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene, toileting hygiene, shower / bathe self, upper body dressing, lower body dressing and personal hygiene. During concurrent observation in Resident 24's room and interview on 1/16/24 at 10:06 AM., with the medical records director (MRD), MRD stated Resident 24's G- tube pump with dry milk on it which is brownish in color and with blackish discoloration on the G-tube pump. MDR also stated it was important to keep the G-tube pump clean for infection control and sanitary reason. During interview on 1/19/24 at 11:22 AM., IPN stated all G-tube pumps should have been disinfected at nighttime or when the nurses change the set up. IPN further stated no dry milk or dirt should be on the G-tube pump for infection control and sanitary reason. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 36 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 2. A review of Resident 19's admission Record indicated the facility admitted Resident 19 on 12/19/22 with diagnosis which include history of falling, difficulty of walking, and lack of coordination. A review of Resident 19's MDS, dated [DATE], indicated Resident 208 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 19 was dependent on toileting hygiene, shower / bathe self, and personal hygiene. A review of Resident 38's admission record indicated the facility admitted Resident 38 on 12/1/20 with diagnosis which include history of falling, anxiety (persistent and excessive worry that interferes with daily activities) and muscle weakness. A review of Resident 38's MDS, dated [DATE], indicated Resident 38 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 38 was dependent on oral hygiene, toileting hygiene, shower / bathe self, and personal hygiene with substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort. During concurrent observation in Room A bathroom and interview on 1/16/24 at 8:52 PM., Certified Nurse Assistant (CAN) 2 stated the toilet seat was broken and the screw was sticking out. CNA 2 also stated it was dangerous and can possibly cut skin of the residents using the toilet seat. CNA 2 further stated two of four resident in Room A uses the bathroom (Resident 19 and Resident 38) 3. During concurrent observation in Room C and interview on 1/16/24 at 9:56 AM, with CNA 1, CNA 1 stated the side drawer on Room C drawers were found to have missing and peeled off vinyl panels leaving the brown wood underneath exposed that appeared to be rough and uneven. CNA 1 further stated sharp edge can possibly cut resident's skin. 4. A review of Resident 3's admission Record indicated the facility admitted Resident 3 on 7/9/27 with diagnosis which include difficulty in walking, anxiety and lack of coordination. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 3 was dependent toilet transfer, tub shower transfer, chair to bed transfer and sit to stand. During concurrent observation in Room B's bathroom and interview on 1/16/24 at 9:09 AM with the director of nursing (DON), the DON stated the toiled seat has brown stuff on it and toilet paper on the floor. During interview on 1/19/24 at 1:12 PM., Resident 3 stated when the toilet seat in his room (Room B) is dirty, Resident 3 feels bad and does not want to use the toilet. Resident 3 also stated bathrooms should be kept clean all the time. 5. During concurrent observation in the hallway and interview on 1/16/24 at 9:17 AM., with license vocational nurse (LVN 3), LVN 3 stated dirty shower chair was not supposed to be at the hallway. LVN 2 also stated the bucket on the shower chair has brownish stuff on it. LVN 3 further stated it was not sanitary and can cause sickness to residents and staff. During interview on 1/18/2024 at 10:47 AM., with registered nurse (RN1), RN1 stated used gloves and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 37 of 38 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 056201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Healthcare Center 112 E. Broadway San Gabriel, CA 91776 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 toilet paper were not supposed to be on the floor to prevent fall/ accident/ infection control and it was not sanitary. RN1 also stated toilet seat screw sticking out and edge of the drawers were supposed to be fixed, it's dangerous can cause skin tears if someone rub against it. RN 1 further stated shower chair with dirty bucket not supposed to be at the hallway for infection control and not sanitary. RN 1 also stated G- tube pump was not supposed to have dry milk and should have been kept clean to prevent infection. Residents Affected - Some During concurrent interview and record review on 1/19/24 at 3:23 PM, with the DON, the DON stated it was indicated in their policy and procedure (P&P) titled Home like environment revised date 2/2021, under policy statement residents are provided with safe, clean comfortable and homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056201 If continuation sheet Page 38 of 38