Health inspection·August 15, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few etc.? He is on drug therapy that requires intensive monitoring for toxicity.? CBC, CMP, TSH before next [appointment] here in 4 weeks around 6/27/2025.? During a concurrent observation and interview on 8/14/2025 at 1:37 PM inside Resident 1's room, Resident 1 was observed sitting on the bed while wearing a nasal canula (a small plastic tube that is used to deliver supplemental oxygen to the resident) that is connected to an oxygen concentrator. The oxygen concentrator was set to deliver 3 LPM of supplemental oxygen. Resident 1 stated he is always using his supplemental oxygen. Resident 1 added the nurses tell him to always use his supplemental oxygen because his oxygen goes down.? ? During a concurrent interview and record review on 8/14/2025 at 3:12 PM with LVN 1, Resident 1's entire medical records was reviewed, including the progress notes, MAR, and physician's orders. LVN 1 stated Resident 1's physician's orders and MAR did not include an order to monitor Resident 1 for any adverse effects associated with the administration of belzutifan and that there was no documentation indicting that Resident 1 was being monitored for adverse effects of belzutifan. LVN 1?could not state why the medication?belzutifan was discontinued on 8/8/2025.? LVN 1 could not state what adverse effects of belzutifan was when administered to a resident. During a concurrent interview and record review on 8/14/2025 at 3:29 PM with RN 1, Resident 1's care plans were reviewed. RN 1 stated that Resident 1's care plans did not indicate the use of the medication belzutifan as a treatment for Resident 1's cancer. RN 1 stated Resident 1's care plan must be specific to Resident 1 and since belzutifan was not indicated on Resident 1's care plan, facility staff were unaware of what to specifically monitor and identify adverse effects while Resident 1 was taking belzutifan. During a concurrent interview and record review on 8/14/2025 at 3:49 PM with RN 1, the Belzutifan drug manufacturer's website page was reviewed. RN 1 stated belzutifan may cause serious side effects, including anemia (a condition in which there is a lower-than-normal number of red blood cells (RBCs) or hemoglobin in the blood) and hypoxemia (condition where there is an abnormally low level of oxygen in the blood). RN 1 stated the web page indicated the person receiving belzutifan who experiences symptoms of anemia or hypoxemia should inform the health care provider or get medical help right away. RN 1 added the web page indicated belzutifan can cause low oxygen levels in [the] body that can be severe and may require [the resident] to stop treatment. RN 1 stated that these adverse effects should be included in the care plan so that staff are aware. During an interview on 8/15/2025 at 3:17 PM with the Director of Nursing (DON), the DON stated resident's care plans should be complete and individualized. The DON stated the care plan must include in must include resident-specific interventions, including prescribed medications. The DON stated belzutifan should be indicated in Resident 1's care plan. The DON stated a that any potential adverse effects of the medication should be noted in the care plan to ensure staff are aware and can monitor for associated signs and symptoms. During a telephone interview conducted on 8/27/2025, at 10:32 AM, Oncologist 1 stated that belzutifan can cause adverse effects such as hypoxemia and anemia. Oncologist 1 reported that Belzutifan was discontinued due to Resident 1's hypoxic condition upon arrival at the oncology clinic on 7/25/2025. Oncologist 1 indicated that prior to Resident 1's oncology visit on 7/25/2025, the facility had not informed Oncologist 1 of Resident 1's increased need for supplemental oxygen. Oncologist 1 added that if Resident 1 had continued receiving belzutifan , Resident 1 was already in a hypoxic state and could have required increased and prolonged supplemental oxygen support. During a review of the facility's policy and procedures (P&P) titled, Comprehensive Plan of Care, dated 12/2016, indicated the comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated the care plan will include treatment goals with measurable objectives, interventions to prevent avoidable decline in function or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 2 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 functional level, and interventions to attempt to manage risk factors. 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: 056413 If continuation sheet Page 3 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary care and services for one (1) of three (3) sampled residents (Resident 1) who had a diagnosis of cancer (a disease characterized by the uncontrolled growth and division of abnormal cells). Specifically, the facility failed to coordinate services related to the care and medication management of Resident 1's cancer, including monitoring for adverse effects and toxicity associated with the administration of Belzutifan (a cancer treatment medication, known to carry risks of anemia [a condition in which the blood lacks sufficient healthy red blood cells to carry adequate oxygen to the body's organs and tissues, leading to symptoms such as fatigue, weakness, and shortness of breath]) and hypoxemia (an abnormal condition characterized by insufficient oxygen supply to the body's tissues). The facility failed to ensure that Resident 1's care was coordinated in accordance with the treatment plans established by Oncologist 1, a physician specializing in cancer treatment. The following deficiencies were identified: Failure to monitor for adverse effects or toxicity associated with Belzutifan, including anemia and hypoxemia. Failure to ensure that the Interdisciplinary Team (IDT) addressed Resident 1's cancer diagnosis, cancer medication management, or coordination of care with the resident's oncologist during the IDT care conference held on 5/13/2025. Failure to notify or consult Oncologist 1 when Resident 1 experienced a change in condition (CIC) on 6/30/2025, with oxygen saturation dropping to 85%, requiring supplemental oxygen. Failure to communicate abnormal blood work results dated 6/19/2025, and 6/11/2025, to Oncologist 1 for review and appropriate follow-up. Failure to ensure that facility staff followed physician orders and scope-of-practice guidelines for the administration of supplemental oxygen for Resident 1, in accordance with the physician's order, which required oxygen to be given only when the resident's oxygen saturation fell below 92%. Failure to reassess the appropriateness of continuing Belzutifan after Resident 1 was hospitalized on [DATE], for acute hypoxic respiratory failure (a sudden inability of the lungs to adequately oxygenate the blood, resulting in low blood oxygen levels) and readmitted to the facility on [DATE], where the medication was continued without documented guidance or monitoring protocols. These failures placed Resident 1 at risk for continued exposure to potentially harmful medication effects without appropriate clinical oversight and represent a lack of coordination and individualized care planning in accordance with professional standards and physician directives. ? During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included left kidney cancer, pancreatic cancer, chronic obstructive pulmonary diseases (COPD, lung disease causing restricted airflow and breathing problems), and heart disease (a range of conditions that affect the heart).??The AR indicated that Family Member (FM) 1 is Resident 1's responsible party. During a review of Resident 1's History and Physical (H&P), dated 5/1/2025, the H&P indicated the resident has a diagnosis of left kidney cancer and liver cancer. The H&P indicated that the resident does not have the capacity to understand and make decisions.? ? During a review of Resident 1's admission Minimum Data Set (MDS-a resident assessment tool), dated 5/8/2025, the MDS indicated that the resident did not require oxygen therapy on admission.? ? During a review of Resident 1's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition (the ability to process thoughts). ? ? During a review of Resident 1's laboratory (lab) results in the facility, the lab results, dated 4/22/2025, the lab results indicated Resident 1's hemoglobin (HgB, an iron-rich protein in the red blood cells that transports oxygen from your lungs to the rest of your body) was 12.6 (Normal hemoglobin for men ranges from 13.5 to 17.5 g/dL. Normal range for women is 12.0 to 15.5 g/dL) and red blood Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 4 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cell count (RBC, [measures the number of red blood cells in your blood]) was 3.91 (normal range for males is 4.7-6.1 million cells/microliter [uL: a unit of measurement] and Females: 4.2-5.4 million cells/uL).? ? During a review of Resident 1's Order Summary Report (OSR) for 5/2025, dated 5/1/2025, the OSR did not include an order for supplemental oxygen.? ? During a review of Resident 1's Oncology Clinic Notes provided by the facility, dated 5/2/2025, the Notes indicated a plan for the resident to switch medications to Belzutifan 120 mg. The notes also indicated for the resident to have a Complete Blood Count, (CBC- a common blood test that provides information about the different types of cells in your blood, including red blood cells, white blood cells, and platelets) and Complete Metabolic Panel, (CMP- a common blood test that provides information about the different types of cells in your blood, including red blood cells, white blood cells, and platelets) prior to the next clinic visit.? During a review of Resident 1's physician order dated 5/9/2025, the order indicated that Resident 1 was to receive Belzutifan Oral Tablet 40 mg, with instructions to administer three tablets by mouth once daily for cancer, totaling 120 mg per day. However, the order did not include instructions to monitor Resident 1 for adverse effects (defined as unintended, undesirable, and potentially harmful reactions to a therapy) or for toxicities associated with Belzutifan which included hypoxemia and anemia. During a review of Resident 1's Interdisciplinary Team (IDT) Care Conference note dated 5/13/2025, at 4:39 PM, the note indicated that the attendees included representatives from the dietary, therapy, and activity departments, as well as the social worker and the MDS nurse. The IDT note did not indicate that Resident 1's Responsible Party (FM 1) was present during the conference. Under the section titled Evaluation/Goals, the note indicated: The goal is to continue receiving all services needed to thrive in long-term care. There were no entries under the section titled Nursing Summary including the subsection Problems/Needs. The IDT notes did not indicate documented evidence that the IDT discussed Resident 1's cancer diagnosis, cancer medication management, or coordination of resident's care with Oncologist 1. During a review of Resident 1's Oncology Clinic Notes provided by the facility, dated 5/30/2025, signed by Oncologist 1, the Notes indicated for the resident to continue taking Belzutifan 120 daily. The Notes also indicated for the resident to be monitored for toxicity, including hypoxemia, anemia, and edema. The Notes further?indicated that the resident was on drug therapy that requires intensive monitoring for toxicity. The Notes also added for Resident 1 to have lab tests CBC, CMP, and TSH (Thyroid Stimulating Hormone or TSH- a blood test that provides the level of a person's TSH, a hormone secreted by the thyroid) prior to the next clinic visit around 6/27/2025.?? During a review of Resident 1's lab results in the facility, the lab results, dated 6/19/2025, the lab results indicated Resident 1's HgB level was abnormally low at 7.9 (4.7 points or 37% lower from the previous lab result on 4/22/2025 when the HgB was 12.6) and RBC was low at 2.46 (1.45 points or 37% lower than the previous lab result on 4/22/2025 when the RBC was 3.91).? During a review of Resident 1's progress notes, the Notes included an entry, dated 6/19/2025, timed at 2:21 PM, and signed by Registered Nurse (RN) 2, that indicated the abnormal lab results dated 6/19/2025 were sent to Medical Doctor (MD) 1, the facility's attending physician and not Oncologist 1. The Notes did not indicate if MD 1 gave orders or instructions. ?? During a review of Resident 1's Oncology Clinic Notes provided by the facility, dated 6/27/2025, the Notes indicated for the resident to have lab tests for CBC and CMP prior to the next Oncology Clinic Visit in 4 weeks.? ? During a review of Resident 1's Change in Condition (CIC) notes, dated 6/30/2025, timed at 10:58 PM, the CIC indicated that the resident had an oxygen saturation of 85% while only on room air (without the resident using supplemental oxygen). The CIC indicated that Medical Doctor (MD) 1 was notified and MD 1 ordered supplemental oxygen.? During a review of Resident 1's physician order with a start date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 5 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 6/30/2025, indicated an order for staff to check Resident 1's [oxygen] saturation [every shift]. The order indicated that Resident 1 may have [oxygen] at 2 to 4 L?if [oxygen] saturation] was below 92% as needed. ? During a review of Resident 1's laboratory (lab) results in the facility, the lab results, dated 7/11/2025, the lab result indicated Resident 1's HgB levels remained abnormally low at 8.8 and RBC was low at 2.65.? During a review of Resident 1's progress notes, the Notes included an entry, dated 7/11/2025, timed at 12:46 PM, and signed by RN 2, that indicated the abnormal lab results dated 7/11/2025 were sent to Medical Doctor (MD) 1, the facility's attending physician and not Oncologist 1. The Notes did not indicate if MD 1 gave orders or instructions. During a review of Resident 1's Oncology Clinic Notes, dated 7/25/2025, signed by Oncologist 1, the Notes indicated that during the clinic visit, Resident 1 came in hypoxic (a state of insufficient oxygen reaching tissues or a specific environment with low oxygen levels) with an oxygen saturation of 84% on room air, required 3 liters per minute (lpm) of oxygen to maintain saturation above 88%. The Notes indicated that the clinic called 911 (a number that is called when there is a need for immediate assistance or care for instances such as a life-threatening medical conditions) and the resident was taken to the emergency room (ER, a section in the hospital that specializes in providing immediate care to life-threatening medical conditions) for hypoxemia evaluation. ? During further review of Resident 1's Oncology Clinic Notes, dated 7/25/2025, signed by Oncologist 1, the Notes indicated that that the resident's desaturation (when a person's oxygen saturation goes down) might be side effect of Belzutifan. The Notes indicated to hold Belzutifan 120 MG daily for hypoxemia, pending further evaluation. The Notes indicated that Resident 1 was on drug therapy that requires intensive monitoring for toxicity. The Notes indicated that the decision was made to escalate level of care to emergency room.? ? During a review of Resident 1's GACH 1 document provided by the facility dated 7/26/2025, the GACH 1 documents indicated that Resident 1 was admitted to GACH 1's ED on 7/25/2025 at 5:20 PM. The GACH documents indicated that Resident 1 had a chief complaint of shortness of breath and that Resident 1 had an oxygen saturation of 85% during the resident's appointment at the Oncology clinic. The GACH 1 document indicated under assessment and plan to hold Belzutifan and administer IV antibiotics.? ? During a review of Resident 1's progress notes, a Notes entry, dated 7/26/2025, timed at 10:34 PM, signed by Registered Nurse (RN) 2, the note indicated Resident 1 returned to the facility from GACH 1 on 7/26/2025 at 6:34 PM with urinary tract infection (UTI, an infection of the urinary system) and respiratory infection. The Notes entry indicated the resident came back with an oxygen saturation of 95% while on room air. The Notes also indicated that Medical Doctor (MD) 1, which was Resident 1's attending physician at the facility, was informed of Resident 1's arrival back to the facility. The progress notes did not indicate documented evidence that the licensed nurses consulted with Oncologist 1 for guidance or monitoring protocols to ensure the appropriateness of continuing Belzutifan after Resident 1 was hospitalized on [DATE], for acute hypoxic respiratory failure. During a review of Resident 1's Medication Administration Record (MAR) for the months of 7/2025 and 8/2025, the MARs indicated that Resident 1 continued to receive Belzutifan 120 mg once a day from 7/27/2025 to 8/8/2025. During a review of Resident 1's Order Audit Report (OAR), dated 8/14/2025, for the medication Belzutifan, the OAR indicated the medication was originally ordered on 5/9/2025. The OAR indicated the medication was discontinued on 8/8/2025, timed at 1:38 PM.? ? During a review of Resident 1's CIC notes, dated 8/15/2025, timed at 11:19 AM, the CIC indicated that Resident 1's oxygen needs increased and that Resident 1 requested to have continuous supplemental oxygen. The CIC indicated that MD 1 ordered Resident 1 to have continuous supplemental oxygen at 2 LPM (liters per minute, a unit of measuring the amount of oxygen delivered per minute) to maintain the oxygen saturation above 92%.? ? During a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 6 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concurrent observation and interview on 8/14/2025 at 1:37 PM inside Resident 1's room, Resident 1 was observed sitting on the bed while wearing a nasal canula (a small plastic tube that is used to deliver supplemental oxygen to the resident) that is connected to an oxygen concentrator. The oxygen concentrator was set to deliver 3 LPM of supplemental oxygen. Resident 1 stated that he always uses his supplemental oxygen. Resident 1 added the nurses tell him to always use his supplemental oxygen because his oxygen goes down.? ? During an interview on 8/14/2025 at 2:14 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 is always using his supplemental oxygen. CNA 1 further stated that Resident 1's oxygen saturation goes low when he is not using his supplemental oxygen.? ? During a concurrent observation and interview on 8/14/2025 at 2:22 PM while CNA 1 was being interviewed on the hallway directly in front of Resident 1's room, Resident 1 was observed standing up inside Resident 1's room, by the door, without wearing his nasal canula. Resident 1 stated he needs help. CNA 1 immediately went inside of the room and placed Resident 1's nasal canula over Resident 1's nares. CNA 1 did not check Resident 1's oxygen saturation nor check the oxygen concentrator for the rate of oxygen delivery.?? ? During a concurrent observation and interview on 8/14/2025 at 2:28 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed checking Resident 1's oxygen saturation. LVN 1 stated Resident 1's oxygen saturation was 96%. LVN 1 stated that the resident's supplemental oxygen was being delivered at a rate of 3 LPM. LVN 1 stated that the resident's supplemental oxygen is ordered only as needed to keep Resident 1's oxygen saturation above 92%.? ? During an interview on 8/14/2025 at 2:41 PM with Registered Nurse (RN) 1 regarding the administration of supplemental oxygen, RN 1 stated only licensed nurses such as the LVN's are able manage the resident's supplemental oxygen. RN 1 added CNAs may not administer oxygen.? ? During the same interview on 8/14/2025 at 2:41 PM with RN 1 regarding notifying physicians for abnormal lab results, RN 1 stated when there is an abnormal lab result, the physician that ordered the lab test must be notified. RN 1 stated an abnormal lab result can be considered a change in condition. RN 1 stated the purpose of initiating a change in condition for a resident was for the proper management of the care of the [residents].? ? During a concurrent interview and record review on 8/14/2025 at 3:12 PM with LVN 1, Resident 1's entire medical records was reviewed, including the progress notes and physician's orders. LVN 1 stated Resident 1's physician's orders did not include an order to monitor Resident 1 for anything such as any adverse effects associated with the administration of Belzutifan. LVN 1 added the resident's records?did?not indicate documented evidence that the resident was monitored for the adverse effects of Belzutifan. LVN 1?could not state why the medication?Belzutifan was discontinued 8/8/2025.? ? During a concurrent interview and record review on 8/14/2025 at 3:12 PM with LVN 1, Resident 1's entire medical records was reviewed, LVN 1 stated the MAR's did not indicate documented evidence that Resident 1 was monitored for adverse effects associated with taking Belzutifan.? ? During a concurrent interview and record review on 8/14/2025, at 3:29 PM with Registered Nurse (RN) 1, Resident 1's lab results and progress notes were reviewed. RN 1 stated that Resident 1's lab results dated 4/22/2025, indicated normal levels of hemoglobin (HgB) and red blood cells (RBC). However, RN 1 noted that subsequent lab results showed declining values: 6/19/2025 - HgB: 7.9, RBC: 2.46 6/11/2025 - HgB: 8.8, RBC: 2.65 7/21/2025 - HgB: 8.3, RBC: 2.49 During the interview, RN 1 stated that these values were low and could indicate that the resident was very anemic. RN 1 added that she would typically call the physician who ordered the lab tests. RN 1 also noted that the nurses progress notes indicated the lab results were sent by the licensed nurses to MD 1, not Oncologist 1. During the same interview and record review on 8/14/2025, at 3:29 PM, Resident 1's care plans were also reviewed. RN 1 stated that the care plans did not include the administration of Belzutifan as an intervention. Although Resident 1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 7 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a care plan for cancer, there was no indication of any interventions to monitor for adverse effects associated with Belzutifan. RN 1 stated that care plans should include the medications a resident is taking, especially when those medications have specific adverse effects that requires monitoring. RN 1 stated that staff would not know what adverse effects to monitor if they are not included in the resident's care plan. During the same concurrent interview and record review on 8/14/2025 at 3:29 PM with RN 1, Resident 1's physician's orders were reviewed, the OSR did not include any orders to monitor the resident for any adverse effects associated while prescribed Belzutifan. RN 1 stated that she was not aware of the adverse effects associated with Belzutifan. ? During a concurrent interview and record review on 8/14/2025 at 3:49 PM with RN 1, the Belzutifan drug manufacturer's website page was reviewed. RN 1 stated the medication may cause serious side effects, including anemia and hypoxemia. RN 1 stated the web page indicated the person receiving Belzutifan who experiences symptoms of anemia or hypoxemia should inform the health care provider or get medical help right away. RN 1 added the web page indicated Belzutifan can cause low oxygen levels in [the] body that can be severe and may require [the resident] to stop treatment.? ? During the same concurrent interview and record review on 8/14/2025 at 3:49 PM with RN 1, Resident 1's CIC notes, dated 6/30/2025, and entire progress notes were reviewed. RN 1 stated that the CIC indicated that Resident 1 had an episode of hypoxemia when the resident's oxygen saturation was at 85%. RN 1 stated the CIC and progress notes indicated only MD 1 was notified, and not Oncologist 1. RN 1 stated?Oncologist 1?should have been notified because the episode of hypoxemia could have been caused by Belzutifan.? ? During the same concurrent interview and record review on 8/14/2025 at 3:49 PM with RN 1, Resident 1's physician's orders from 1/2025 to current were reviewed. RN 1 stated Resident 1 did not have an order for supplemental oxygen until the resident had an episode of hypoxemia on 6/30/2025.?RN 1 stated the physician's order for Belzutifan was added but did not include an order to monitor the resident for adverse effects or toxicities associated with the administration of Belzutifan, which included hypoxemia and anemia.? ? ? During another concurrent observation and interview on 8/14/2025 at 4:18 PM with RN 1, Resident 1 was observed lying in bed. RN 1 stated the resident was still using his supplemental oxygen. RN 1 stated the resident was currently receiving supplemental oxygen at a rate of 3 LPM.? ? During a concurrent observation and interview on 8/15/2025 at 9:23 AM with CNA 2, Resident 1 was observed lying in bed while wearing his nasal cannula. CNA 2 stated Resident 1 always?uses his supplemental oxygen.? ? During an observation on 8/15/2025 at 9:37 AM inside Resident 1's room, Resident 1 was observed not wearing his nasal cannula and was walking from the bathroom to his bed with CNA 2. Resident 1 was assisted to the bed by CNA 2. CNA 2 was then observed placing Resident 1's nasal cannula on Resident 1. CNA 2 did not check Resident 1's oxygen saturation nor the rate of delivery of Resident 1's oxygen concentrator.? ? During a concurrent observation and interview on 8/15/2025 at 10:09 AM with LVN 1 inside Resident 1's room, Resident 1 was observed lying in bed while wearing his nasal cannula. LVN 1 stated Resident 1 is receiving supplemental oxygen at a rate of 3 LPM. Resident 1 stated he does not want to remove his oxygen because he needs it.?? ? During the same concurrent observation and interview on 8/15/2025 at 10:09 AM with LVN 1 inside Resident 1's room, LVN 1 stated the CNA should inform the licensed nurses before placing the resident's supplemental oxygen because CNA's are not licensed to administer oxygen. LVN 1 stated Resident 1's order for supplemental oxygen was ordered as needed and must be followed. LVN 1 added prior to administering supplemental oxygen to Resident 1, the resident's oxygen saturation must be checked because the order indicated only to administer supplemental oxygen when the oxygen saturation is below 92%. LVN 1 further added the resident could be getting too much oxygen if the parameters are not followed.?? ? During another concurrent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 8 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observation and interview on 8/15/2025 at 11:01 AM with LVN 1 inside Resident 1's room, Resident 1 was observed walking from the bathroom to the bed without wearing his nasal cannula while being assisted by CNA 2. When Resident 1 reached his bed, CNA 2 was observed grabbing Resident 1's nasal cannula and was about to place it on Resident 1. LVN 1 stopped CNA 2 and LVN 1 stated CNAs must inform the LVN prior to administering oxygen. LVN 1 proceeded to check Resident 1's oxygen saturation and stated Resident 1's oxygen saturation is 95%.? LVN 1 stated the resident does not require oxygen since?Resident 1's?oxygen saturation?was?above 92%.?? ? During an interview on 8/15/2025 at 11:08 AM with CNA 2, CNA 2 stated he was not aware that the nurses must be informed prior to administering oxygen. CNA 2 stated he was not trained to administer medications. CNA 2 further added he does not know about, nor has he read Resident 1's order for supplemental oxygen.?? ? During a concurrent observation and interview on 8/15/2025 at 11:39 AM with the Director of Nursing (DON), Resident 1 was observed using his nasal cannula and receiving oxygen. The DON stated he administered Resident 1's supplemental oxygen because he checked Resident 1's oxygen saturation and it was 90%. The DON stated he is in the process of informing the physician that Resident 1 needs an order for continuous oxygen supplementation.?? ? During a concurrent interview and record review on 8/15/2025 at 12:36 PM with RN 2, Resident 1's Oncology clinic progress notes and physician's orders were reviewed. RN 2 stated the lab tests ordered for 6/19/2025, 7/11/2025, and 7/21/2025 were ordered by Oncologist 1. RN 2 stated that the lab results were sent to MD 1 and not Oncologist 1, as indicated in Resident 1's progress notes. RN 2 added the physician who ordered the lab tests should be made aware of the lab results.? During a concurrent interview and record review on 8/15/2025 at 12:45 PM with Registered Nurse (RN) 2, Resident 1's progress notes were reviewed. RN 2 stated Resident 1 went to the Oncology clinic on 7/25/2025 but the clinic decided to transfer the resident to the GACH via 911. RN 2 stated Resident 1 was only in the GACH for one night. RN 2 stated when a resident was only out of the facility for less than three days, the resident is able to come back to the facility and the same previous physician ordered were followed, unless new orders were prescribed from the hospital. RN 2 stated when Resident 1 was readmitted back to the facility on 7/26/2025, she informed Resident 1's primary care physician, MD 1, but did not consult with Oncologist 1. RN 2 stated that the resident's progress notes did not indicate documented evidence that anyone from the facility followed up with Oncologist 1 after Resident 1 was readmitted back to the facility on 7/26/2025. During an interview on 8/15/2025 at 12:48 PM with RN 2, RN 2 stated that Resident 1 needs the oxygen all the time now. RN 2 added Resident 1 looks okay but when you check the [oxygen saturation], it is down to 85%. RN 2 added even with 4 [LPM], [the oxygen saturation] would go up only to 94%. RN 2 further added everyone knows that he always needs oxygen.? ? During a concurrent interview and record review on 8/15/2025 at 1:45 PM with RN 2, Resident 1's entire medical records was reviewed. RN 2 stated Resident 1 went for an appointment to the Oncology clinic on 7/25/2025 but the clinic sent the resident to the GACH 1 ED. ? During a concurrent interview and record review on 8/15/2025 at 3:17 PM with the DON, Resident 1's entire medical records, including the Oncology clinic notes, dated 5/30/2025, were reviewed. The DON stated the Oncology clinic notes, dated 5/30/2025, indicated the resident must be monitored for belzutifan toxicity, including anemia and hypoxemia. The DON stated there were no documented evidence that the licensed nurses monitored Resident 1 for belzutifan toxicity. The DON added the nurses should have also consulted?Oncologist 1?when the resident had an episode of hypoxia on 6/30/2025. The DON stated it is the nurses' responsibility to follow all of Resident 1's physician's plans (MD 1 and Oncologist 1). ? During the same concurrent interview and record review on 8/15/2025 at 3:17 PM with the DON, Resident 1's entire medical records, including the Oncology clinic notes, dated 7/25/2025, were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 9 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed. The DON stated the Oncology clinic notes, dated 7/25/2025, indicated for belzutifan to be held. The DON stated the MAR indicated the nurses continued to administer belzutifan until it was finally discontinued on 8/8/2025. The DON stated the nurses were responsible to follow up with the clinic if the resident came back from an appointment without any notes from the clinic. The DON further added following up with the clinic is important because the physician might provide new orders, changes, or requests.? ? During the same interview on 8/15/2025 at 3:17 PM with the DON, the DON stated it is important for the nurses to monitor the toxicity or potential adverse effects because if not, the nurses would not be aware that such toxicities might be happening. The DON added it is important to monitor the resident because such toxicities must be reported to the physician.?? During a telephone interview on 8/27/2025 at 10:32 AM with Oncologist 1, Oncologist 1 stated Belzutifan can cause adverse effects of hypoxemia and anemia. Oncologist 1 stated belzutifan was discontinued due to the Resident 1's hypoxic state when the resident arrived at the Oncology clinic on 7/25/2025.?Oncologist 1 stated that prior to?Resident 1's oncology?visit on 7/25/2025, Oncologist 1 was not notified by the facility of the Resident 1's increasing needs for supplemental oxygen. Oncologist 1?stated?the facility did not notify Oncologist 1 of Resident 1's?change in condition (CIC) on 6/30/2025, when Resident 1 experienced a low oxygen of ??85% on room air and was then ordered to receive supplemental oxygen. Oncologist 1 also stated that if the facility had informed her of the resident's increasing supplemental oxygen needs and the CIC on 6/30/2025, she could have made a decision to consider the discontinuation of Belzutifan at an earlier time. Oncologist 1 stated the facility did not coordinate or clarified Resident 1's care after readmission back to the facility on 7/26/2025. Oncologist 1 stated, if Resident 1 continued to receive Belzutifan after it was supposed to be discontinued, Resident 1, who was already hypoxic, could potentially require the need for more supplemental oxygen and at a longer duration.? During a review of the facility's policy and procedures titled, Medication Administration, undated, indicated the facility's P&P are established to assure the most complete and accurate implementation of physician's medication orders. The P&P indicated the nurse who receives the prescriber's order shall be responsible for its complete implementation. The P&P added that complete implementation includes proper transcribing, ordering of medications, and all other steps involved in carrying out of the order. The P&P also indicated that medications shall be administered only upon the written order of a person lawfully authorized to prescribe for and treat human illnesses.? ? During a review of the facility's P&P titled, Lab work, Ordering of, undated, the P&P indicated a licensed nurse will review the reports and initiate appropriate measures. The P&P also indicated the nurse will phone the lab results to the physician. ? ? During a review of the facility's P&P titled, Physician Order Processing, undated, indicated?the following:? It is?facility's policy that all physician orders are complete and clearly defined to assure accurate implementation by appropriate health care members.?? All written physician orders are reviewed by the license nurse receiving the order for completeness, accuracy and clarity. ? Orders will include a description complete enough to ensure clarity of physician's plan of care.? Medication/treatment orders will be transcribed onto the appropriate resident administration record.? ? The nurse will transcribe the complete physician order onto the physician order sheet.? ? During a review of the facility's P&P titled, Medication Therapy, dated 12/2017, indicated it is the facility's policy that medication being used for each resident shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. The P&P indicated each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. The P&P indicated staff will review the resident's medication regimen to identify whether potential or suspected side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 10 of 11 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 056413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temple City Healthcare 5101 Tyler Avenue Temple City, CA 91780 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 0684 Level of Harm - Minimal harm or potential for actual harm effects are present. The P&P also indicated the physician will identify situations where medications should be tapered, discontinued, or changes to another medication when the presence of clinically significant adverse consequences monitoring suggest that a medication should be reduced or discontinued entirely.? ? Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056413 If continuation sheet Page 11 of 11