Health inspection·March 10, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. A review of Resident 17's admission Record indicated, Resident 17 was admitted to facility on 12/21/14, and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and schizophrenia. A review of Resident 17's MDS dated [DATE], indicated Resident 17 had severely impaired cognition. The MDS indicated Resident 1 required extensive assistance from staff for transfers, dressing, toilet use, eating and personal hygiene. A review of Resident 26's admission Record indicated, Resident 26 was admitted to facility on 10/2/14, and readmitted on [DATE] with diagnoses of Alzheimer's disease, hypertension (high blood pressure), and schizophrenia. A review of Resident 26's MDS dated [DATE], indicated the resident had severely impaired cognition. The MDS indicated Resident 26 required extensive assistance from staff for transfers, dressing, toilet use, eating and personal hygiene. A review of Resident 26's care plan titled, Resident has Self Care Deficits, reviewed 1/09/23, indicated the facility staff would assist Resident 26 with ADLs as needed. During a dining observation on 3/7/23, at 11:41 AM, Resident 26 was sitting in a Geri chair (a large, padded chair with wheeled base, designed to assist seniors with limited mobility) while in the TV room. NA1 was standing on Resident 26's left side while feeding her. During an interview on 3/7/23, at 11:47 AM, NA1 stated she should sit down next to Resident 26 whenever she feeds the resident because it will make Resident 26 feel more comfortable and relaxed. During a dining observation on 3/7/23, at 11:50 AM, Resident 17 was sitting at the table in the TV room. Resident 17 had a white towel over her chest that was being used as a bib. CNA1 fed Resident 17 while sitting on the resident's right side. Resident 17 was looking towards her left side. Resident 17 was not able to make eye contact with CNA 1. CNA 1 used the white towel to wipe food from Resident 17's face. During an interview on 3/7/23, at 11:59 AM, CNA 1 stated she used the towel to wipe spilled food from Resident 17's mouth. CNA 1 stated she will not use a napkin if the resident was using a towel as a bib. CNA 1 stated she should use a napkin to protect the resident's dignity. CNA 1 stated Resident 17 always look to the left while seated at the table. CNA 1 stated residents might not feel respected if there was no eye contact while being fed. During a dining observation on 3/7/23, at 12:02 PM, Resident 1 was sitting in a Geri chair while in the TV room. CNA 2 fed lunch to Resident 1. CNA 2 sat on Resident 1's right side. Resident 1 was leaning to his left side and could not see CNA 2's face. During an interview on 3/7/23, at 12:18 PM, the Director of Nursing (DON) stated residents should be fed in a respectful manner. The DON stated there is a risk that residents would feel rushed if staff were standing while feeding the residents. During an interview on 3/9/23, at 9:46 AM, CNA 2 stated she sat on the opposite side where Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 2 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0550 Level of Harm - Minimal harm or potential for actual harm 1 was facing. CNA 2 stated she should have sat where the resident could see her face while she fed Resident 1; CNA 2 stated it was important so that the resident will feel respected. A review of the facility's undated policy and procedure titled, Assistance with Meals, indicated residents who could not feed themselves would be fed with attention to safety, comfort, and dignity, for example: Residents Affected - Some a. not standing over residents while assisting them with meals. b. avoiding the use of bibs or clothing protectors instead of napkins unless requested by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 3 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer Advance Directives (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) to two of two sampled residents (Resident 6 and Resident 41). This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making for Residents 6 and 41. Findings: 1. A review of the facility's admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included, schizoaffective disorder (a mental health problem where you experience psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality] as well as mood symptoms) and type 2 diabetes mellitus (a chronic condition that affects the way your body metabolizes sugar). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/6/23, indicated Resident 6 had clear speech, usually understood others, and usually made self-understood. Resident 6 had cognitive impairment (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 6 required supervision with setup only during walking, eating and transfers. 2. A review of the facility's admission Record indicated Resident 41 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships) and malignant neoplasm of colon (colon cancer). A review of MDS, dated [DATE], indicated Resident 41 had clear speech, sometimes understood others, and sometimes made self-understood. Resident 41 had cognitive impairment. Resident 41 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assistance during bed mobility, toilet use, and personal hygiene. A medical record review indicated there were no AD in Resident 6 and Resident 41's records. During an interview on 3/7/2023, at 2:07 PM, The Social Service Director (SSD) stated there were no AD acknowledgment forms in Resident 6 or Resident 41's medical records. The SSD stated the facility did not offer ADs to Resident 6 or Resident 41. The SSD stated AD acknowledgment forms should be included in the facility's admission package and offered to all residents (in general) upon admission and revised when there were changes. The SSD stated it was a resident's and responsible party's right to be provided with an AD form to make decisions regarding their choice of treatment and care. The SSD stated it was very important for residents to know their rights. A review of the facility's policy and procedure titled Advance Directive Acknowledgement not dated, indicated, it is the policy of this facility to support the rights of residents in making decisions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 4 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0578 Level of Harm - Minimal harm or potential for actual harm regarding their care and treatment. Advance directives are defined as written instructions to express a person's choice on treatment or to designated someone else to make healthcare decisions when the resident is unable. An Advance Directive acknowledgement will be provided to residents and/or responsible parties upon admission. They will be informed on the availability of option so medical care providers advance directive regarding the resident's health care decisions. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 5 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 one of five sampled residents (Resident 40) was free from the use of physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff) in accordance with the facility's policy on Physical Restraint,. The facility did not conduct a restraint assessment nor receive a physician's order before using side rails on Resident 40's bed. Residents Affected - Few This deficient practice had the potential to affect the resident's physical and psychological well-being, safety, and quality of life. (Cross reference F689 and F700) Findings: A review of Resident 40's admission Record indicated, Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/08/22, indicated Resident 40 had severely impaired cognition (never/rarely made decisions). The MDS indicated Resident 40 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for transfers, dressing, toilet use, and personal hygiene. During an observation of Resident 40's room and interview with Licensed Vocational Nurse 1 (LVN1) on 3/8/23, at 9:10 AM, Resident 40 was lying in bed. Resident 40's bed had 2 upper side rails up. LVN 1 stated the bed was provided by hospice (medical service designed to give supportive care to people in the final phase of a terminal illness) company when she was admitted and that the bed rails were already attached to the bed when it arrived. LVN 1 stated Resident 40 was not assessed for the need of the side rails. LVN 1 stated Resident 40 did not have an order for the use of siderails, assessment of side rails, nor care plan for the use of side rails. During an interview with LVN 1 and record review of Resident 40's clinical record on 3/9/23 at 2:24 PM, LVN 1 stated Resident 40's physician did not order the use of side rails for the resident. A review of Resident 40's Restraint-Physical (Initial Evaluation), dated 11/29/22, did not indicate the use of side rails. A review of the facility's undated policy and procedure titled, Physical Restraint, indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the residence body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one 's body. The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 6 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0604 a. Specific type of restraint. Level of Harm - Minimal harm or potential for actual harm b. Purpose of the restraint. c. Time and place of application. Residents Affected - Few d. Approaches to prevent decrease functioning when applicable. e. Informed consent obtained from resident or from surrogate decision maker. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 7 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool) assessment for one of two sampled residents (Resident 39) selected for Resident Assessment review. Residents Affected - Some This deficient practice had the potential to negatively affect Resident 39's plan of care and delivery of necessary care and services. Findings: A review of Resident 39's admission Record indicated the facility admitted Resident 39 on 4/29/2022, with diagnoses that included unspecified dementia (loss of memory and other mental abilities severe enough to interfere with daily life) without behavioral disturbance and schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). A review of Resident 39's MDS assessments indicated the last quarterly assessment was completed on 11/16/2022. There were no other MDS assessments completed since 11/16/2022. During an interview and concurrent review of Resident 39's medical record with the MDS Coordinator on 3/10/2023 8:44 AM, the MDS Coordinator stated he missed the target completion date of the quarterly assessment for Resident 39 on 2/16/2023. The MDS Coordinator verified that Resident 39's quarterly MDS was submitted more than 14 days late. The MDS Coordinator stated Resident 39's MDS dated [DATE] was submitted on 3/7/2023. The MDS Coordinator stated the submission was late due to personal reasons. A review of the facility-provided CMS Resident Assessment Instrument (RAI) User's Manual Version 3.0 dated 10/2019, indicated: Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three followed by an Annual (comprehensive) assessment. The next Quarterly assessment would be scheduled within 92 days after the ARD of the SCSA or SCPA, and the next comprehensive assessment would be scheduled within 366 days after the Assessment Reference Date (ARD) of the SCSA or SCPA. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 8 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0641 Ensure each resident receives an accurate assessment. 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 code the Minimum Data Set (MDS, a standardized assessment and care planning tool) assessment accurately in the areas of Preadmission Screening and Resident Review (PASRR, screening for individuals with mental disorder and intellectual disability for most appropriate setting for their needs) for three of 42 sampled residents (Resident 5, 27, and 42) identified as PASRR Level II (a comprehensive evaluation for serious mental disorder and/or intellectual disability conducted by the state-designated authority that determines the appropriate setting and services for the resident). Residents Affected - Some This had the potential to place Resident 5, 27, and 42 at risk for unmet care needs and inappropriate placement. Findings: 1. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 2/5/2010, with diagnoses that included convulsion (an abnormal, involuntary contraction of the muscles most typically seen with certain seizure disorders), paranoid schizophrenia (a type of mental disease in which the person has delusions (false beliefs) that a person or some individuals are plotting against them or their family members) and obsessive compulsive personality disorder (mental condition in which a person is preoccupied with rules, orderliness and control). A review of Resident 5's medical record indicated Resident 5 had a PASRR Level II Determination Report dated 4/6/2022. The report indicated Resident 5 was determined to have a significant medical and/or mental health condition with mental stressors that required skilled nursing care. A review of Resident 5's annual MDS dated [DATE] and quarterly MDS assessment dated [DATE], indicated Resident 5 had a Brief Interview for Mental Status (BIMS) score of 03, indicating that the resident had severely impaired cognitive (ability to think and reason) skills. Both MDS assessments indicated under Section I that Resident 5's active diagnoses included psychiatric/mood disorder such as psychotic disorder (a mental disorder characterized by a disconnection from reality) and schizophrenia. The MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] indicated No to question A1500 which asked if Resident 5 had been evaluated and considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During an interview with the MDS Coordinator (nurse in charge of the comprehensive assessment) on 3/8/2023 at 9:54 AM, the MDS Coordinator confirmed that Resident 5 was identified as a Level II PASRR. The MDS Coordinator stated that Resident 5 had a diagnosis of schizophrenia, but did not fit in the category of serious mental illness. The MDS Coordinator stated that the behavior Resident 5 demonstrated was not serious since Resident 5 was not a danger to himself or others. According to https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms, schizophrenia is a serious mental disorder in which people interpret reality abnormally. 2. A review of Resident 27's admission record indicated the facility admitted Resident 27 on 11/8/2022, with diagnoses that included major depressive disorder, schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), anxiety, and psychosis (severe mental disorder that causes abnormal thinking and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 9 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0641 perception). Level of Harm - Minimal harm or potential for actual harm A review of Resident 27's most recent Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 11/15/2022, indicated the resident was not coded for PASRR Level II which meant that the resident was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. Residents Affected - Some A review of Resident 27's quarterly MDS dated [DATE], indicated Resident 27 had a Brief Interview for Mental Status (BIMS) score of 03, indicating that the resident had severely impaired cognitive (ability to think and reason) skills. The MDS assessment indicated under Section I that Resident's 27 active diagnoses included psychiatric/mood disorder such as anxiety, depression, psychotic disorder, and schizophrenia. During an interview with the MDS Coordinator on 3/8/2023 at 9:12 AM, the MDS Coordinator confirmed that Resident 27's last MDS assessment dated [DATE], was not coded for Level II PASRR even though Resident 27 had been evaluated and determined by the state Level II PASRR process as having a significant mental health condition on 12/19/2022. The MDS Coordinator stated that Resident 27's behavior did not present any serious behavior that could be danger to herself and others. 3. A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 3/23/2022, with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), psychosis (severe mental disorder that causes abnormal thinking and perception) and bipolar disorder[a mental condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)]. A review of Resident 42's medical record indicated Resident 42 had a PASRR Level II Determination Report dated 4/28/2022. The report indicated Resident 42 was determined to have a significant medical and/or mental health condition with mental stressors that required skilled nursing care. A review of Resident 42's quarterly Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 12/28/2022, indicated a No to question A1500 which asked if Resident 42 had been evaluated by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During a concurrent interview and review of Resident 42's medical record on 3/10/2023 at 1:10 PM, the MDS Coordinator confirmed that Resident 42's admission diagnoses included schizophrenia and bipolar disorder. The MDS Coordinator stated that he did not code MDS Section A1500 because Resident 42's schizophrenia diagnosis was not considered as serious mental illness. A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2019, page A-23, indicated, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or intellectual/developmental disability (ID/DD) or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 10 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Some 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** d. A review of the facility's admission Record indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included, pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (life-threatening complication of an infection), respiratory failure (a serious condition that makes it difficult to breathe on your own) and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting your mouth and stomach). A review of MDS, dated [DATE] indicated, Resident 19 had clear speech, was sometimes understood, and sometimes understood by others. Resident 19 had severe impaired cognition. Resident 19 required extensive physical assistance from one-person during bed mobility, transfers, eating and personal hygiene. During an observation on 3/7/2023, at 9:32 AM, Resident 19 was lying flat on Resident 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Resident 19's head of bed indicated, per MD 1, Please have resident up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]. During a concurrent observation on 3/7/2023, at 12:19 PM, Resident 19 was lying flat in his bed with eyes closed. During an interview and concurrent record review on 3/9/2023, at 9:46 AM, the DON stated MD 1 gave a verbal order to have Resident 19 up in the wheelchair during meals and to remain sitting upright for 1-2 hours was not transcribed into Resident 19's order summary report and there was no care plan that included interventions to reflect this order. The DON stated Resident 19 was at high risk for recurrent aspiration pneumonia and the purpose of MD 1's order was to prevent aspiration pneumonia for Resident 19. The DON stated MD 1's order should be reflected as an intervention in Resident 19's care plan. The DON stated care plans should be resident-centered to meet resident's medical, nursing, mental and psychosocial needs that were identified during assessments. A review of Resident 19's care plan indicated Resident 19 was at risk for aspiration of food and liquids secondary to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and dysphagia (difficulty swallowing). Resident 19's care plan's interventions did not include Resident 19 had to be up in the wheelchair during meals and had to remain sitting upright for 1-2 hours after meals. A review of the facility's policy and procedure titled The Resident Care Plan undated, indicated professionals from each discipline write the portion of the plan that pertains to their field, including their approach to the resident's current problems. Care plans are considered comprehensive in nature and should be reviewed in its entirety. Problems, goals, and approaches can be addressed in more than one or different areas of the plan of care. The care plan generally includes identification or medical, nursing, and psychosocial needs; goals stated in measurable/observable terms; approaches (staff action) to meet the above goats; discipline/staff responsible for approaches; reassessment and change as needed to reflect current status. Steps included record care necessitated by the resident's individual needs. The nursing care plan acts as a communication instrument between nurses and other disciplines, it contains information of importance for all nurses concerning nursing approach and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 11 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 problem solving. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure four of 16 sampled residents (Residents 19, 26, 36, and 40) had a comprehensive care plan to address specific resident needs, and in accordance with the facility's care plan policy and procedures, by failing to, Residents Affected - Some a. Ensure Resident 26 had a care plan that indicated specific interventions to prevent aspiration (when something you swallow enters your lungs). b. Create a care plan that addressed Resident 36's inability to understand how to use the call light. c. Create a care plan that addressed Resident 40's inability to understand how to use the call light. d. Ensure Resident 19's care plan indicated interventions with specific instructions to prevent the reoccurrence of aspiration and based on Medical Doctor 1's (MD 1) order. These deficient practices had the potential to result in Residents 26, 36, 40, and 19 not to receive the necessary care and services in accordance with their specific needs. Findings: a. A review of Resident 26's admission Record indicated, Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE] with Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hypertension (high blood pressure), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/4/2023, indicated Resident 26 had severe impaired cognition (ability to understand and process information). Resident 26 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff during transfers, dressing, toilet use, eating and personal hygiene. During an interview and concurrent record review on 03/10/23, on 9:08 AM, the Director of Nursing (DON) stated Resident 26's care plan titled, Aspiration. Resident is at risk for aspiration of food and liquid secondary to: Edentulous [lacking teeth], revised on 3/09/2023, did not include specific interventions for Resident 26. The DON stated she had called the doctor, received further instruction, and updated the care plan to include aspiration precautions for Resident 26. The DON stated there was a risk Resident 26 would aspirate if the care plan interventions were not specific. A review of Resident 26's care plan titled, Aspiration. Resident is at risk for aspiration of food and liquid secondary to: Edentulous, revised on 3/09/2023, indicated nursing interventions to keep Resident 26's head elevated at least 30 degrees during meals, and the head to remain elevated 30 to 45 degrees for at least 15 minutes after meals if tolerated. b. A review of Resident 36's admission Record indicated, Resident 36 was admitted to facility on 03/20/2020, and readmitted on [DATE] with multiple diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 12 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 schizophrenia, and hypertension. Level of Harm - Minimal harm or potential for actual harm A review of Resident 36's MDS, dated [DATE], indicated the resident had severe impaired cognition and required extensive assistance from staff during transfers, dressing, toilet use, eating and personal hygiene Residents Affected - Some During an observation and interview on 3/07/2023, at 2:54 PM, Resident 36 was lying in bed and his call light cord was at the foot of his bed. Certified Nursing Assistant (CNA) 7 stated Resident 36 was too confused to use his call light. During an interview and concurrent record review on 3/09/2023, at 8:44 AM, Licensed Vocational Nurse (LVN) 1 confirmed Resident 36 did not have a care plan that addressed his inability to use a call light. LVN 1 stated Resident 36 did not use his call light. c. A review of Resident 40's admission Record indicated, Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE] with multiple diagnoses including Alzheimer's disease, adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), and schizophrenia. A review of Resident 40's MDS, dated [DATE], indicated the Resident 40 had severe impaired cognition and required extensive assistance from staff for transfers, dressing, toilet use, and personal hygiene. During an observation and concurrent interview on 3/08/2023, at 9:10 AM, Resident 40 was lying bed and the call light was not within Resident 40's reach. LVN 1 stated Resident 40 did not use the call light and LVN 1 came to the door to check if Resident 40 needed assistance. During an interview on 3/09/2023, at 2:57 PM, the DON confirmed Resident 40 did not use the call light. The DON stated a care plan should have been created that addressed that issue. The DON stated residents (in general) who do not use their call lights should have care plans with resident specific interventions. The DON stated the potential negative outcome, when care plans are not created, include resident's needs might not be met. A review of the facility's policy and procedure titled, The Care Plan, undated, indicated the care plan would provide an individualized nursing care plan and promote continuity of resident care. The care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. The nursing section of the care plan must indicate long and short-term goals with plans for restorative and rehabilitation nursing care. The care plan includes care necessitated by the residents' individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 13 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 28's admission Record indicated the facility admitted Resident 28 on 1/25/2023, with diagnoses that included fracture of the left femur (broken thighbone), dementia (decline in mental ability severe enough to interfere with daily life), and hypertension (high blood pressure). Residents Affected - Few A review of Resident 28's Physician Order dated 1/25/2023, indicated for the staff to apply Geri-sleeves daily for safety and protection of fragile skin due to senile purpura (purplish spots appear on the arms and legs due to the thinness of the skin and frailty of the blood vessels). A review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/2/2023, indicated the resident rarely/never made herself understood, rarely/never understood others, and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 28 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from the staff for bed mobility transfer, locomotion on and off unit, and toilet use. The MDS indicated Resident 27 was at risk for developing skin injuries. A review of Resident 28's Care Plan dated 2/2/2023, indicated Resident 28 was at risk for skin discoloration, bruising secondary to fragile skin (thin skin that tears easily), aging process, and cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The care plan indicated for the staff to apply Geri-sleeves to bilateral upper extremities (BUE) due to senile purpura. During a concurrent observation and interview with Certified Nursing Assistant (CNA 3) on 3/7/2023 at 2:23 PM, Resident 28 was lying in bed without the Geri-sleeves on Resident 28's BUE. CNA 3 stated Resident 28 did not have Geri-sleeves when she received the resident in the morning. CNA 3 stated she was not aware that Resident 28 needed to wear Geri-sleeves. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/7/2023 at 2:23 PM, LVN 1 stated Geri-sleeves were used to protect the skin of residents with fragile skin. LVN 1 stated the staff needed to apply the Geri-sleeves on Resident 28 to protect the resident's skin. According to https://www.woundsinternational.com), consideration should be made within the healthcare setting for patients who are at risk of skin tears, in terms of minimizing the risk of potential trauma. This should include factors such as: 1. Avoiding friction and shearing - ensuring to use good manual handling techniques and using products such as hoists and glide sheets where required 2. Ensuring a generally safe environment - e.g. ensuring adequate lighting and removing any manual obstacles - particularly in patients who may have impaired vision or cognition issues 3. Encouraging use of protective clothing/devices where required, such as shin guards, long sleeves and/or tubular bandages/stockinette. 1. Based on observation, interview, and record review, the facility failed to provide care and services for one of two sampled residents (Resident 19), who had history of aspiration pneumonia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 14 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Immediate jeopardy to resident health or safety Residents Affected - Few (swelling and infection of the lungs caused when food or liquid is breathed into the airway or lungs instead of being swallowed), by failing to: Ensure Licensed Vocational Nurse 1 (LVN 1) transcribed (put into written or printed form) and followed Medical Doctor 1's (MD 1's) verbal order (spoken orders given by a physician to a person authorized to receive and record the orders in accordance with applicable policies, laws, and regulations) according to the facility's policy and procedure titled, Physician Orders and Telephone Orders. MD 1 gave LVN 1 a verbal order for Resident 19 to remain sitting upright for one to two hours after eating his meals (breakfast, lunch, and dinner) due to Resident 19 had a history of hospitalizations for sepsis (life-threatening complication of an infection) that resulted from aspiration pneumonia. Resident 19 required intubation (a breathing tube placed through the mouth, down the throat, and into the lungs), the use of a ventilator (a life support machine that moves breathable air in and out of the lungs when a person is unable to breath on his/her own), and admission to the Intensive Care Unit (ICU, a unit of a hospital that provides intensive treatment and close monitoring for seriously ill patients). These deficient practices had the potential to result in recurrent (occurring often or repeatedly) aspiration pneumonia, re-hospitalization (being hospitalized again), intubation, and death for Resident 19. On 3/9/2023, at 12:20 PM, during a recertification survey, the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) regarding the facility's failure to ensure Resident 19 remained sitting upright for one to two hours after meals, per MD 1's verbal order, in the presence of the Administrator (ADM) and the Director of Nursing (DON). The CDPH informed the ADM and the DON regarding the facility's deficient practice could cause recurrent aspiration pneumonia that could lead to serious harm to Resident 19's health. On 3/10/2023, at 1:05 PM, the facility's ADM submitted an acceptable Plan of Action (POA/IJ removal plan, a detailed plan to address the IJ findings) while onsite, the surveyors verified the implementations of the POA by observation, interview, and record review. The CDPH confirmed the removal of the IJ on 3/10/2023, at 2:37 PM while onsite, in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the followings: A. On 3/9/2023 and 3/10/2023, the DON provided in services to all nurses (licensed nurses and certified nursing assistants) from all shifts regarding aspiration precautions (practices that help prevent food or fluid get into the airway/the passage by which air reaches the lungs). The in-services indicated for all nurses to keep Resident 19 sitting upright in the wheelchair during and after meals. B. On 3/9/2023, the DON called MD 1 and MD 1 ordered for Resident 19 to remain sitting upright in the wheelchair for 30 minutes after each meal. C. On 3/9/2023, the Speech Therapist (ST, also called a speech-language pathologist is a specialist who assesses, diagnoses, and treats people with communication and swallowing problems) completed a speech screening for Resident 19 who was on a puree diet (blended foods that do not need to chew, for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 15 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 people who have trouble chewing or swallowing). Resident 19 tolerated puree diet. Level of Harm - Immediate jeopardy to resident health or safety D. On 3/9/2023, the DON and the Director of Staff Development (DSD) observed Resident 19 eating dinner while sitting upright in Resident 19's wheelchair and remained sitting upright for 30 minutes after dinner. Cross Reference F711 and F656. Residents Affected - Few 2. Based on observation, interview, and record review, the he facility also failed to provide the necessary care and treatment for one of two sampled residents (Resident 28) in a total resident sample of 42 by failing to apply the Geri-sleeves (a breathable cotton-blend material that protects against skin tears caused by friction and shearing) to Resident 28 as ordered by the physician. This deficient practice had the potential to cause injury to Resident 28's skin. Findings: A review of Resident 19's admission Record indicated Resident 19 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included, pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (a life-threatening medical emergency in which the body responds improperly to an infection,) respiratory failure (a serious condition that makes it difficult to breathe), and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting the mouth and stomach). A review of Resident 19's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive [ability to think and process information], behavioral, or functional domains) Assessment Form, dated 12/6/2022, indicated Resident 19 had shortness of breath (difficulty breathing), and trouble breathing when lying flat. The COC indicated at 11 AM, Resident 19 was sitting up in the wheelchair waiting for lunch. At 12:30 PM, Resident 19 was found breathing fast, looked pale with audible congestion (a sign that something blocks the airway), and rhonchi (low-pitched sounds usually indicating secretions [saliva or mucus] in the airway) in both lungs by auscultation (listening by using a stethoscope [an instrument that's used to hear the heart beats or breathings inside the chest]). The COC indicated the facility called 911 (phone number for emergency services) and the paramedics (a healthcare professional who responds to emergency calls for medical help outside of a hospital) transferred Resident 19 to the hospital. A review of Resident 19's General Acute Care Hospital 1 (GACH 1) admission History and Physical Exam, dated 12/6/2022, indicated Resident 19 had shortness of breath, was tachypneic (breathing that is abnormally rapid and shallow) and required intubation. Resident 19 was admitted to GACH 1 for aspiration pneumonia. The GACH record indicated Resident 19 had acute (sudden) respiratory failure and depended on a respirator (depended on a mechanical ventilation/breathing machine to sustain respiration/breathing). A review of Resident 19's GACH 1 Multi-Discipline Progress Notes, dated 12/23/2022, indicated Resident 19 received a Modified Barium Swallow Study (MBSS, speech therapy evaluation with special X-ray [image study that takes pictures of the bones and soft tissues] to find the reason for difficulty swallowing) on 12/17/2022. The MBSS results indicated Resident 19 had moderate dysphagia (difficulty swallowing) characterized by poor base of the tongue retraction (action of drawing something back), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 16 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Immediate jeopardy to resident health or safety Residents Affected - Few and silent laryngeal aspiration (when the residents accidentally inhale food or liquid in the airway, and they do not know it) of thin and mildly thick liquids. The note indicated feeding precautions included for Resident 19 to sit entirely upright, and for staff (in general) to monitor Resident 19 for fever spike (sharp rises in body temperature) after meals, coughing, choking (severe difficulty in breathing because an object or food lodges in the throat or windpipe blocking the flow of air) or throat clearing during meals. A review of Resident 19's GACH 1 Discharge summary, dated [DATE], indicated Resident 1 had sepsis due to aspiration pneumonia, recurrent aspiration pneumonia, acute hypoxemic respiratory failure (low blood oxygen level resulting from sudden impairment of gas exchange between the lungs and the blood which may cause shortness of breath, anxiety [a feeling of worry], confusion, cardiac dysfunction [heart failure], and cardiac arrest [no heartbeat]), and respirator dependence. The discharge summary indicated for Resident 19 to have puree diet with moderately thickened liquid (liquid mixed with thickener to help prevent choking and stop fluid from entering the lungs for safer swallowing), and for staff (in general) to observe strict aspiration precautions during and immediately after meals. A review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/22/2023, indicated Resident 19 had severe impaired cognition (ability to understand and process information). Resident 19 required extensive physical assistance (resident involved in activity, staff provide weight-bearing support) from one-person during bed mobility, transfers (moving a resident from one flat surface to another), eating and personal hygiene. A review of Resident 1's MD 1 Progress Notes, dated 1/4/2023, indicated Resident 19 needed oxygen and completed a seven-day course of Levaquin (medication that treats a wide range of infections) to treat the aspiration pneumonia. The note indicated strict aspiration precautions were to be followed given Resident 19's high-risk for re-aspiration. During an observation on 3/7/2023, at 9:32 AM, Resident 19 was lying flat on Resident 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Resident 19's head of bed indicated, per MD 1, Please have resident up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]. During an observation on 3/7/2023, at 11:40 AM, Resident 19 was sitting up in wheelchair eating his lunch. Resident 19 had puree diet and thicken liquid on Resident 19's meal tray. During an observation and a concurrent interview with Resident 19 on 3/7/2023, at 12:19 PM, Resident 19 was lying in his bed flat. Resident 19 nodded his head when surveyor asked if he wanted to get up. During an interview on 3/7/2023 at 12:22 PM, LVN 2 stated she was aware of MD1's order for Resident 19 to remain sitting upright for one to two hours after meals due to the signage with instruction posted over Resident 19's head of bed. LVN 2 stated Resident 19 had GERD, and history of aspiration pneumonia. LVN 2 stated Resident 19 needed to be sitting upright after meals as aspiration precautions to prevent gastric secretions backflow (a flowing back or returning especially toward a source) to the airway. During a concurrent interview Certified Nursing Assistant 5 (CNA 5), CNA 5 stated she and another staff (unidentified) assisted Resident 19 back to bed after Resident 19 finished his lunch. CNA 5 stated she was aware of MD 1's instruction to have Resident 19 sitting upright in the wheelchair after meals. CNA 5 stated there were two signages with instructions to have Resident 19 up in wheelchair for meals and to remain sitting upright for 1-2 hrs. posted on the wall above Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 17 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 19's head of bed, and at the back of Resident 19's door. Level of Harm - Immediate jeopardy to resident health or safety During an interview, on 3/8/2023 at 1:33 PM, and a concurrent review of Resident 19's physician orders, care plans, and nurses progress notes, dated from 12/24/2022 to 3/6/2023, the DON stated the posted signages in Resident 19's room were to remind staff (in general) to keep Resident 19 sitting upright in the wheelchair for one to two hours after meals for aspiration precautions. The DON stated not following aspiration precautions could put Resident 19 on a ventilator again and or Resident 19 could die from choking. The DON reviewed Resident 19's physician orders and stated there was no written order for Resident 19 to sit upright in the wheelchair during and after meals. The DON continued to review Resident 19's care plan, nurses notes, and stated there was no documentation in the nurse's progress notes and no care plan interventions corelating with the aspiration precautions. The DON stated LVN 1 who received MD 1's instruction/verbal order needed to document MD 1's instruction/verbal order in Resident 19's progress notes. Residents Affected - Few During a telephone interview on 3/9/2023 at 8:44 AM, MD 1 stated Resident 19 had a history of aspiration pneumonia which required hospitalization. MD 1 stated he gave a verbal order to LVN 1 during an onsite visit shortly after Resident 19 readmitted to the facility from the hospital. MD 1 stated he did not remember the date that he gave the verbal order. MD 1 stated the order was to have Resident 19 sitting upright in the wheelchair during meals and to remain sitting upright for one to two hours after meals. During an interview on 3/9/2023 at 9:12 AM, LVN 1 stated after Resident 19 was readmitted to the facility (on 12/24/2022), MD 1 told her to make sure to keep Resident 19 sitting upright in the wheelchair at least one to two hours after meals. LVN 1 stated she did not remember the date when MD 1 gave her the verbal order. LVN 1 stated she did not enter MD 1's verbal order in Resident 19's physician order summary. LVN 1 stated she did not document MD 1's verbal order in the nurse's notes and did not update Resident 19's care plan interventions for aspiration precautions. LVN 1 stated Resident 19 needed to remain sitting upright after meals due to Resident 19's history of GERD, aspiration pneumonia to prevent recurrent aspiration pneumonia, rehospitalization, sepsis, and death. During an interview on 3/9/2023, at 9:46 AM, the DON stated LVN 1 who received MD 1's verbal order needed to update Resident 19's care plan regarding aspiration precautions. A review of the facility's policy and procedure titled, Aspiration Precaution, undated, indicated Avoid lying down right after feeding. Remain sitting in a upright position for at least 20 to 30 minutes to prevent aspiration. A review of the facility's policy and procedure titled, Physician Orders and Telephone Orders, dated 1/2004, indicated All orders must be specific and complete with necessary details to carry out the prescribed order. The policy indicated All orders shall indicate how the order was received, the name of the prescriber, the name of the attending physician and the name of the nurse taking the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 18 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards (refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident) for 3 of 42 sampled residents (Resident 35, 42, and 40) by failing to: 1. Provide a smoking apron to Resident 35 while smoking a cigarette as indicated in the resident's care plan and ensure that ashtrays were available in the smoking areas as indicated in the facility's Smoking Policy & Procedure. 2. Provide a smoking apron to Resident 42 while smoking a cigarette as indicated in the resident's care plan and ensure that ashtrays were available in the smoking areas as indicated in the facility's Smoking Policy & Procedure. 3. Ensure that Resident 40's bed alarm was turned on while the resident was lying in her bed. These deficient practices had the potential to cause injuries to Resident 35 and 42 and had the potential to cause a fall which could result in injuries for Resident 40. Findings: 1. A review of Resident 35's admission Record indicated the facility admitted Resident 35 on 6/18/2021, with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), psychotic disturbance (severe mental disorder that causes abnormal thinking and perception), schizophrenia (a type of mental disease in which the person has delusions or false beliefs), and anxiety disorder. A review of Resident 35's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 12/21/2022, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision with activities of daily living (ADLs). A review of Resident 35's Care Plan dated 12/27/2022, indicated Resident 35 was a smoker and required supervision while smoking. The care plan goal indicated Resident 35 will be able to smoke according to the facility policy with precautions taken for the resident's safety and will have no smoke-related incidents in the facility. The nursing interventions included for Resident 35 to use a smoking apron. During an observation on 3/8/2023 at 11:30 AM, Resident 35 was observed out in the designated smoking area. Resident 35 was observed smoking a cigarette and shaking the ashes onto the grass. Resident 35 was not wearing a smoking apron. There was no ashtray observed next to the resident. A facility staff was observed supervising other residents sitting at another table, approximately 10 feet away from Resident 35, and was not aware if Resident 35 properly disposed his ashes and cigarette butts. Resident 35 refused to be interviewed. During a concurrent interview and review of Resident 35's care plan on 3/9/23 at 2:06 PM, the Director of Staff Development (DSD) stated that ashtrays must be provided in the smoking areas due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 19 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Some risk for fire on the resident's clothes and the grass. The DSD looked around and found one metal ashtray located behind one of the chairs. The DSD stated Resident 35's care plan dated 12/27/2022, indicated the resident was a smoker and needed to use a smoking apron. 2. A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 3/23/2022, with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), psychosis (severe mental disorder that causes abnormal thinking and perception) and bipolar disorder (a mental condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)). A review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/28/2022, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision with activities of daily living (ADLs). A review of Resident 42's Care Plan dated 12/28/2022, indicated Resident 42 was a smoker and required supervision while smoking. The care plan goal indicated Resident 42 will be able to smoke according to the facility policy with precautions taken for the resident's safety and will have no smoke-related incidents in the facility. The nursing interventions included for Resident 35 to use a smoking apron. During a concurrent interview and observation on 3/7/23, at 10:55 AM, Resident 42 was observed in the smoking area. Resident 42 stated that he smoked three times a day, mostly after meals, and the staff were in the smoking area to watch them. Resident 42 was observed not wearing a smoking apron. There was no ashtray near Resident 42. A facility staff was observed about 10 feet away from Resident 42 and did not monitor if the resident properly disposed his ashes and cigarette butts. During an interview with the Activity Assistant (AA) on 3/9/2023, at 10:09 AM, the AA stated that there was only one ashtray available in the smoking area. The AA stated that the ashtray needed to be close to the residents when they smoke. The AA stated that the facility only had one smoking apron available for the residents and she would tell the facility to buy more. A review of the facility's policy and procedures titled, Smoking Policy & Procedure, undated, indicated the designated smoking areas will be under supervision, as needed per Smoking Assessment, by facility staff. Ashtrays will be of non-combustible material and will be provided in smoking areas. 3. A review of Resident 40's admission Record indicated, Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/08/22, indicated Resident 40 had severely impaired cognition (never/rarely made decisions). The MDS indicated Resident 40 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for transfers, dressing, toilet use, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 20 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Some During an observation of Resident 40's room and interview with Licensed Vocational Nurse 1 (LVN 1) on 3/8/23, at 9:10 AM, Resident 40 was lying in bed. Resident 40's bed had 2 upper side rails up. A bed pad alarm (device to alert staff to respond quickly and intervene to assist the resident) was observed hanging at the head part of Resident 40's bed. LVN 1 stated the bed alarm was turned off. A review of Resident 40's Restraint-Physical (Initial Evaluation), dated 11/29/22, indicated for Resident 40 to use a bed pad alarm when in bed. A review of Resident 40's Order Summary Report, for March 2023, indicated for staff to apply bed pad alarm when the resident is in bed for safety. A review of Resident 40's care plan, titled Sensor Pad Alarm, reviewed 12/13/22, indicated for staff to apply bed pad alarm as ordered and to monitor the bed pad alarm for good working condition and proper placement as needed. A review of the facility's undated policy and procedure titled, Personal Alarm, indicated the facility would use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting staff to a potential fall. Nursing will monitor proper functioning and positioning of personal alarm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 21 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a bed rail entrapment assessment was completed for one of five sampled residents (Resident 40) who had bed side rails on the bed. This deficient practice had the potential to cause strangulation, entanglement, and/or other serious injuries to the resident. (Cross Reference F604 and F689) Findings: A review of Resident 40's admission Record indicated, Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/08/22, indicated Resident 40 had severely impaired cognition (never/rarely made decisions). The MDS indicated Resident 40 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for transfers, dressing, toilet use, and personal hygiene. During an observation of Resident 40's room and interview with Licensed Vocational Nurse 1 (LVN 1) on 3/8/23, at 9:10 AM, Resident 40 was lying in bed. Resident 40's bed had two upper side rails up. LVN 1 stated the bed was provided by hospice (medical service designed to give supportive care to people in the final phase of a terminal illness) company when she was admitted and that the bed rails were already attached to the bed when it arrived. LVN 1 stated all residents with bed side rails should get a bed rail safety and entrapment assessment before using the side rails. LVN 1 stated residents could get hurt or stuck if they were not assessed before using the bed side rails. A review of Resident 40's Restraint-Physical (Initial Evaluation), dated 11/29/22, did not indicate the use of side rails. A review of the facility's undated policy and procedure titled, Policy for Resident's Bed Entrapment, indicated the facility will conduct inspections of all bed frames mattresses and bed rails to identify areas of possible entrapment to ensure safety. The facility would complete physical restraint assessment and document the proper medical symptoms that warrant the use of bed rails. The facility will include the residence positioning, movements, or weight in bed safety assessment. The facility would implement useful interventions to reduce the gap between the bed frames, mattresses and bed rails, and the gaps between bed to reduce the risk for entrapment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 22 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Medical Doctor 1 (MD 1) failed to ensure a verbal order that indicated aspiration precautions was signed, dated, and entered in the Order Summary Report in a timely manner for one of one sampled resident (Resident 19), and as indicated in the facility's policy, titled, Physician Visit. Resident 19 had a history of aspiration pneumonia (swelling and infection of the lungs caused when food or liquid is breathed into the airway or lungs instead of being swallowed) and was identified as high risk for recurrent aspiration pneumonia. This deficient practice had the potential to result in the reoccurrence of aspiration pneumonia and hospitalization for Resident 19. Findings: A review of the facility's admission Record indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included, pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (life-threatening complication of an infection), respiratory failure (a serious condition that makes it difficult to breathe on your own) and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting your mouth and stomach). A review of Resident 1's MD 1 Progress Notes, electronically signed on 1/4/2023, at 5:56 PM, indicated strict aspiration precautions were to be followed given Resident 19's high-risk for re-aspiration. A review of Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/22/2023 indicated, Resident 19 had clear speech, was sometimes understood, and sometimes understood by others. Resident 19 had severe impaired cognition (ability to understand and process information). Resident 19 required extensive physical assistance (resident involved in activity, staff provide wright-bearing support) from one-person during bed mobility, transfers (moving a resident from one flat surface to another), eating and personal hygiene. A review of Resident 19's Order Summary Report, active orders as of 3/1/2023, signed and dated by MD 1 on 2/27/2023, this report did not indicate MD 1's order for Resident 19 to remain sitting upright for 1-2 hours after meals. During an observation on 3/7/2023, at 9:32 AM, Resident 19 was lying flat on Resident 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Resident 19's head of bed indicated, per MD 1, Please have resident up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]. During an observation on 3/7/2023, at 11:40 AM, Resident 19 was sitting up in wheelchair eating his lunch. Resident 19 had puree diet and thicken liquid on Resident 19's meal tray. During a concurrent observation on 3/7/2023, at 12:19 PM, Resident 19 was lying in his bed flat with eyes closed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 23 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/7/2023, at 12:22 PM, Licensed Vocational Nurse 2 (LVN 2) stated she was aware of MD1's order for Resident 19 to remain sitting upright for one to two hours after meals to follow the signage with instructions posted over Resident 19's head of bed. LVN 2 stated Resident 19 had GERD, and history of aspiration pneumonia. LVN 2 stated Resident 19 needed to be sitting upright after meals to follow aspiration precautions and prevent gastric secretion backflow (a flowing back or returning especially toward a source) to the airway. During a concurrent interview, Certified Nursing Assistant 5 (CNA 5) stated she and another staff (unidentified) assisted Resident 19 back to bed after Resident 19 finished his lunch. CNA 5 stated she was aware of MD 1's instruction to have Resident 19 sitting upright in the wheelchair after meals. CNA 5 stated there were two signages with instructions to have Resident 19 up in wheelchair for meals and to remain sitting upright for 1-2 hrs. posted on the wall above Resident 19's head of bed, and at the back of Resident 19's door. During a telephone interview on 3/9/2023, at 8:44 AM, MD 1 stated Resident 19 had a history of aspiration pneumonia which required hospitalization. MD 1 stated he gave a verbal order to LVN 1 during an onsite visit shortly after Resident 19 was readmitted to the facility from the hospital. MD 1 stated the order was to have Resident 19 sitting upright in the wheelchair during meals and to remain sitting upright for one to two hours after meals. During an interview on 3/9/2023, at 9:12 AM, LVN 1 stated, during MD 1's onsite visit to Resident 19 and after Resident 19 was readmitted to the facility, MD 1 told her to keep Resident 19 sitting upright in the wheelchair at least one to two hours after meals. LVN 1 stated she did not remember the date when MD 1 gave her the verbal order. LVN 1 stated she did not enter MD 1's verbal order in Resident 19's physician order summary. During a concurrent interview on 3/9/2023, at 2:35 PM, LVN 1 stated normally after a physician (in general) gave verbal orders, licensed nurses wrote the orders on the physician order sheet or entered the order into the facility's Point Click Care system (PCC, healthcare software used for electronic health record). LVN 1 stated the PCC generated order summary reports for the physician to sign and date during the next facility visit. LVN 1 stated MD 1 visited Resident 19 every month. During a concurrent telephone interview on 3/10/2023, at 11:49 AM, MD 1 stated he gave the verbal order for Resident 19 to remain sitting upright for 1-2 hours after meals to LVN 1 at end of January 2023 or early February 2023. MD 1 stated he could not remember the exact date. MD 1 stated the facility process for verbal orders included the license nurse wrote the order on the telephone order sheet and MD 1 signed during the next facility visit. MD 1 stated he did not remember if he signed the verbal order given to LVN 1. MD 1 stated the order should have been in Resident 19's order summary report. MD 1 stated he reviewed, signed (if no errors), and dated, all orders (in general) in the order summary reports every month. A review of the facility's policy and procedure titled Physician Visit dated 1/2004 indicated, the resident's total program of care, including medications and treatments, is reviewed during the physician's visit in accordance with the appropriate scheduled visit. At this time, all orders shall be signed and dated, and progress notes written, signed and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 24 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure that the posting of the nurse staffing information was current and updated on a daily basis. Residents Affected - Some This deficient practice had the potential to inaccurately reflect the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift which could misinform the residents and the visitors of the facility. Findings: During the initial tour observation on 3/7/2023 at 8:09 AM, the Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 3/3/2023 (four days old), was observed posted in a bulletin board located in the facility lobby. During an interview with the admission Coordinator (AC) on 3/10/2023 at 2:37 PM, the AC stated that the Daily Nurse Staffing Information should be updated at the start of each shift per day. The AC stated that during the weekday, it was his responsibility to update the staffing information. The AC stated that on the weekends, the Registered Nurse or Charge Nurses on duty were responsible to update the staffing information. The AC stated that it should be updated at the start of each shift and posted daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 25 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure to place a tray card (a record card with resident information, diet type and food preferences) on resident's meal tray for one of five sampled residents (Resident 7). This deficient practice had the potential for Resident 7 to receive the incorrect diet and food which could result in weight loss, malnutrition, or accident. Findings: A review of Resident 7's admission Record indicated the facility readmitted Resident 7 on 1/10/2020, with diagnoses that included schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships) and epilepsy (a central nervous system disorder in which brain activity becomes abnormal, marked by sudden episodes of sensory disturbance, loss of consciousness). A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/18/2023, indicated Resident 7 had clear speech, understood others, and made self-understood. The MDS indicated Resident 7 had cognitive impairment (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist for bed mobility, eating and personal hygiene. During a concurrent dining observation and interview with Certified Nursing assistant 4 (CNA 4) on 3/7/2023 at 11:59 AM, CNA 4 was sitting next to Resident 7 in the dining room assisting Resident 7 to eat. Resident 7's lunch tray did not have a tray card on it. CNA 4 stated there should be a tray card on every resident's tray for each meal. CNA 4 stated she did not know where Resident 7's tray card was. CNA 4 stated the tray card would indicate the resident's name and diet type including food consistency, allergies, likes and dislikes (preferences). CNA 4 stated the staff assisting the resident with eating should double check that the resident's meal matches the diet/food indicated on the residents' tray card before feeding the resident. CNA 4 stated it was important to have the resident's tray card on the resident's tray so the staff would know if the correct diet was provided to the correct resident. CNA 4 stated the staff needed to verify the resident's diet/food against the resident's tray card to ensure accuracy of diet and consistency and prevent the resident from receiving the wrong diet that could cause allergy, malnutrition, and safety concerns. A review of Resident 7's Order Summary Report as of 3/9/2023, indicated for Resident 7 to receive No Added Salt (NAS), Low-fat, Low Cholesterol (a waxy substance in blood) diet, minced and moist texture, and thin consistency. A review of the facility's policy and procedures titled, Meal Service, revised in 2019, indicated tray cards are periodically checked by the dietary service supervisor or consultant dietitian for accuracy. Individual resident trays will have a tray card which identifies the residents name, room number, diet order. Also stated on the card: portion size, food preferences and beverage preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 26 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 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 follow proper food sanitation and handling practices by failing to label one container with mixed fruit cocktail, one container with apple sauce and three opened plastic bags of tortillas with the open date or expiration date. These deficient practices had the potential to result in food-borne illnesses to the residents. Findings: During a tour observation of the facility's kitchen with the Certified Dietary Manager (CDM) on 3/7/2023 at 8:16 AM, one square container of mixed fruit cocktail, one square container of apple sauce, and three opened bags of tortillas were observed on the shelves inside the facility's walk-in refrigerator. The CDM stated food items should be labeled with the open date or expiration date after the food items have been removed from its original packaging for resident food safety and to prevent food borne illnesses. The CDM stated residents could get sick if they eat spoiled food and cause decline of their health conditions. During an interview on 3/7/2023 at 8:35 AM, the Kitchen Aid (KA) stated she mixed the fruit and apple sauce this morning and forgot to label the container. The KA stated she should label the container with the open date or expiration date for all food taken out from its original packaging to make sure they were still safe to eat and to prevent food borne illnesses. A review of the facility's policy and procedures titled, Refrigerator/Freezer Storage, revised in 2019, indicated all items should be properly covered, dated, and labeled, food items should have the following appropriate dates: delivery date, open date, and thaw date. Frozen food that taken from the original packaging should be labeled and dated. A review of the facility's policy and procedures titled, Storage of Canned and Dry Goods, revised in 2019, indicated plastic or metal containers, or re-sealable plastic bags will be used for staples and opened packages. Food items will be dated and labeled when placed in the containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 27 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0825 Provide or get specialized rehabilitative services as required for a resident. 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 perform an annual rehabilitation evaluation by a speech therapist (ST, a professional who provides support and care for persons who have difficulties with communication, eating, drinking, and swallowing) for one of 42 sampled residents (Resident 19). Residents Affected - Few This deficient practice had the potential for Resident 19 to not receive the necessary care and treatment to meet his needs. Findings: A review of Resident 19's admission Record indicated the facility originally admitted Resident 19 on 9/22/2017, and readmitted on [DATE] with diagnoses that included pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (a life-threatening medical emergency in which the body responds improperly to an infection,) respiratory failure (a serious condition that makes it difficult to breathe), and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting the mouth and stomach). A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/22/2023, indicated Resident 19 had clear speech, sometimes made self-understood, and sometimes understood others. The MDS indicated Resident 19 had cognitive impairment (trouble remembering, concentrating, or making decisions that affect everyday life) and required extensive assistance (resident involved in activity, staff provide wright-bearing support) with one-person physical assist for bed mobility, transfer, eating, and personal hygiene. During an observation on 3/7/2023, at 9:32 AM, Resident 19 was lying flat on Resident 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Resident 19's head of bed indicated, per MD 1, Please have resident up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]. During an observation on 3/7/2023 at 11:40 AM, Resident 19 was sitting up in wheelchair eating his lunch. Resident 19 had puree diet (blended foods that do not need to chew, for people who have trouble chewing or swallowing) and thicken liquid (liquid mixed with thickener to help prevent choking and stop fluid from entering the lungs for safer swallowing) on his meal tray. During an interview and concurrent review of Resident 19's medical record on 3/10/2023 at 8:26 AM, the Director of Rehabilitation (DOR) stated the ST performed speech therapy screening and evaluation upon residents' (in general) admission, readmission, annually, and as needed. The DOR stated the ST screened Resident 19 upon his admission on [DATE] and readmission on [DATE]. The DOR confirmed that Resident 19 did not receive a routine annual ST screening in 2022. The DOR stated it was important for the ST to evaluate Resident 19 annually to check for any changes in communication, safe swallowing ability, and any decline in health condition. The DOR stated the ST may adjust the treatment plan based on the resident's screening results. The DOR stated Resident 19's ST annual screening for 2022 was missed. During an interview on 3/10/2023 at 8:48 AM, the Medical Record Director (MR) stated she audited rehabilitation services quarterly and upon admission to check if residents (in general) received the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 28 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few necessary services. The MR stated ST services should be done upon admission, readmission and annually. The MR stated during her audits, she would print out the rehabilitation services that were due and would give them to each department director. The MR stated Resident 19's annual ST screening was due in early 2022 and did not know why the ST screening was missed. A review of the facility's policy and procedures titled, Rehabilitation Services, undated, indicated skilled rehabilitation services shall be made available to residents to promote recovery, improve, and maintain functional independence, and prevent any further decline. Goals of the speech therapy service included: to assist residents in achieving maximum independence in communication and cognition and to assist residents in developing or maintaining a safe swallowing ability. A review of the facility's policy and procedures titled, Standards Expected by rehab Providers, undated, indicated timely evaluations and admissions screenings are to be provided by licensed therapist and quarterly screenings are to be completed by support personnel (assistants). If a change of function is identified, licensed therapists shall reassess. Annual screenings and joint mobility assessment are to be completed by licensed therapist. Speech pathologists (ST) are to screen enteral feeders and residents with communication disorders to assure needs are met and there is no change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 29 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI) team failed to: Residents Affected - Many a. Identify, develop, and implement Performance Improvement Projects (PIP) based on high-risk and/or high-volume and or/ problem-prone areas affecting the health and safety of residents when they did not have a PIP for psychotropic medication reduction. b. Include quantifiable data (data that can be counted or measured) collection in its PIP related to falls. This deficient practice had the potential for the residents not to receive appropriate care and safety interventions. Findings: a. During an interview on 3/10/23, at 2:39 PM, the facility Administrator (ADM) stated the facility had a population with a high psychotropic medication use rate. ADM stated the QAPI team's only PIP was for fall prevention. A review of the facility's Resident Census and Conditions of Residents, dated 3/7/23, indicated the facility had 38 residents who took psychotropic medications. b. During an interview on 3/10/23, at 2:39 PM, the Administrator (ADM) stated the QAPI team had identified falls as being an issue to address with a PIP. The ADM stated a resident (unidentified) had fallen recently. The resident was agitated and had a diagnosis of dementia. The ADM stated the facility staff need a buddy system to prevent similar falls in the future. The ADM stated the only data the team was tracking was the number of resident falls and that the team was not collecting any data identifying risks or effects contributing to residents' falls. A review of the facility's Performance Improvement Project Worksheet, dated 1/18/23, indicated the PIP team was not collecting any quantifiable data related to interventions addressing identified risks contributing to resident falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 30 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow its Antibiotic Stewardship Program [a coordinated program designed to improve and measure the appropriate use of antimicrobial agents (agents that kill microorganisms or stops their growth) by promoting the selection of optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration] for one of three sampled residents (Resident 32) on an antibiotic (drug used to treat bacterial infection) in a total sample of 42 residents by failing to: Residents Affected - Few 1. Communicate to Resident 32's physician about the results of Resident 32's Surveillance Data Collection Form for Skin, Soft Tissue, and Mucosal Infections that included Resident 32's signs and symptoms of infection not meeting the McGeer Criteria (set of criteria used to determine true infection) before the administration of Clindamycin (an antibiotic used to treat various types of infections). This deficient practice had the potential to result in ineffective antibiotic therapy, increased risk of adverse effects (unwanted or harmful effect of a drug) and antibiotic resistance (the ability of bacteria or other microbes to resist the effects of an antibiotic) for Resident 32. Findings: A review of Resident 32's admission Record indicated the facility admitted Resident 32 on 12/28/2022, with diagnoses that included hypertension (high blood pressure), surgical aftercare following surgery on the genitourinary system (surgery or operation done to the parts of the body that play a role in reproduction, getting rid of waste products in the form of urine, or both), and history of cancer of the endometrium (the layer of tissue that lines the uterus). A review of Resident 32's physician order dated 2/13/2023, indicated for Resident 32 to receive Clindamycin Hydrochloride (HCl) Oral Capsule 300 milligrams (mg, unit of measurement), give one capsule by mouth three times a day for abscess on surgical site for seven days. A review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/15/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 32 required extensive assistance with bed mobility, transfer, walking, dressing and personal hygiene. The MDS indicated Resident 32 received an antibiotic during the last three days. During a concurrent interview and review of Resident 32's Surveillance Data Collection Form (Skin, Soft Tissue, and Mucosal Infections), dated 2/13/2023, on 3/8/2023 at 12:34 PM, the Infection Preventionist (IP, staff responsible for the facility infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of infections) stated the following: 1. For cellulitis, soft tissue, or wound infection, at least one of the following criteria must be present: Pus present at wound, skin, or soft tissue site. The IP stated this section was not checked off. 2. New or increasing presence of at least 4 of the following sign or symptom (s/s) sub-criteria: a. Heat at the affected site; b. Redness at the affected site; c. Swelling at the affected site; d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 31 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tenderness or pain at the affected site; e. serous drainage at the affected site; and f. one constitutional criterion. The IP stated in this section, only three of four s/s were checked off. The IP stated the charge nurse reported to Resident 32's physician the following, Abnormal abscess forming below previous wound site, feels hard around the abscess and is red, warm to touch. Resident verbalizes there's some discomfort to area as well. The IP confirmed Resident 32's Surveillance Data Collection Form was incomplete or missing some information. The IP stated a completed surveillance data collection form was important to ensure residents meet the criteria for the use of antibiotics to prevent resident from developing resistance to antibiotics. The IP stated if the resident did not meet the criteria for antibiotic use according to the antibiotic surveillance form, the resident's physician must be notified. A review of the facility's policy and procedures titled, Policy for Antimicrobial Stewardship Program, undated, indicated, It is the policy of the facility to implement an Antimicrobial Stewardship Program that will focus on a coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optimal antimicrobial drug regiment including dosing, duration of therapy and route of administration. The program goal indicated: 1. To achieve best clinical outcomes related to antimicrobial use while minimizing the unintended consequences of the antimicrobial use and reducing the treatment related cost. 2. To curb the emergence and spread of antimicrobial resurgent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 32 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' bedrooms measured at least 80 square feet (sq. ft., a unit of measurement) per resident in multiple resident bedrooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 17, 18, 19, 20, 21, 22, and 24). This deficient practice had the potential to cause the residents not to have enough room and limit the space for the staff to provide services for the residents. Findings: During an observation on 3/10/23, at 10:55AM, Maintenance Manager (MM) was asked to measure three of 20 random rooms in the facility. room [ROOM NUMBER] measured 14 feet (ft) 6 inches (in) by(x) 10 ft., room [ROOM NUMBER] measured 14 ft 6 in. x 10 ft., and room [ROOM NUMBER] measured 14 ft x 10 ft. During an interview with Resident 9 on 3/10/23, at 12:05 PM, Resident 9 stated he had plenty of room to move around in his room while using his wheelchair. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 3/10/23, at 12:13 PM, LVN 2 stated there was enough space for staff to care for the residents in their rooms. A review of the facility's undated room waiver request letter indicated the facility requested a room waiver for the following rooms that provided less than 80 square feet per resident: Room # # of beds Sq. ft. Required Sq. ft. 1 2 140 160 2 2 140 160 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 33 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 3 Level of Harm - Potential for minimal harm 2 140 Residents Affected - Many 160 4 2 140 160 5 2 140 160 6 2 140 160 7 2 140 160 8 2 140 160 9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 34 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 2 Level of Harm - Potential for minimal harm 140 160 Residents Affected - Many 10 2 140 160 11 2 140 160 12 2 140 160 16 2 140 160 17 2 140 160 18 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 35 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 140 Level of Harm - Potential for minimal harm 160 19 Residents Affected - Many 2 140 160 20 2 140 160 21 2 140 160 22 2 140 160 24 4 308 320 The room waiver request letter indicated there was reasonable privacy, closet, and storage space provided in each resident's room and enough room for staff to provide nursing care. The letter indicated all the rooms had windows and no rooms below ground level and that the health and safety of each resident would not be jeopardized by the waiver. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 36 of 37 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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 The department is recommending approval of the room waiver request. Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 37 of 37