Health inspection·January 19, 2024

F 0603 On 1/18/2024, staff immediately removed the utility carts that blocked Residents 1, 2, and 3 from leaving RM [ROOM NUMBER]. Level of Harm - Immediate jeopardy to resident health or safety 2. Residents Affected - Some On 1/18/2024, the DON assessed Residents 1, 2, and 3. All three (3) residents were at their baseline condition without any signs or symptoms (S/S - observed or detectable signs, and experienced symptoms of an illness, injury, or condition) of distress. 3. On 1/18/2024, the psychiatrist evaluated Residents 1, 2, and 3 via telehealth and informed the facility that all three (3) residents did not experience any S/S of psychosocial distress. There were no new orders. 4. On 1/18/2024, the DON notified Residents 1, 2, and 3' s Medical Doctor (MD 1) regarding the involuntary seclusion with no new order. 5. On 1/18/2024, the DON notified the family members of Residents 1, 2, and 3 regarding the incident of involuntary seclusion. 6. On 1/18/2024, the ADM provided an in-service to CNA 1 regarding abuse prevention, including involuntary seclusion. 7. On 1/18/2024, CNA 1 was suspended, followed by further disciplinary action, including termination based on the determination/conclusion of the investigation. 8. On 1/18/2024, the ADM and DON notified the staff of the findings stated in the IJ template, dated 1/18/2024, and gave in-services regarding the abuse policy. During the in-services, the ADM and DON emphasized the importance of not confining any resident to a room or area against his/her will. 9. On 1/19/2024, the maintenance supervisor and the housekeeping supervisor stored all clean linens in the linen storage in different hallways and removed all the clean linen carts from the floor. Any linen carts required to be on the floor were placed against the wall, avoiding blocking the entrances, including all residents' rooms. 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 2 of 9 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 01/19/2024 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 0603 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 1/19/2024, the DON updated the plan of care for Resident 1 who had episodes of grabbing cups from other resident's rooms. The care plan included the interventions of storing extra clean cups inside Resident 1's room and encouraged Resident 1 to participate in group activities to keep Resident 1 occupied. (Cross reference F656) Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (serious mental illness in which people interpret reality abnormally), unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and obsessive-compulsive personality disorder (a pervasive obsession with order, perfectionism, control, and specific ways of doing things). During a review of Resident 1's History and Physical (H&P), dated 2/19/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated 11/17/2023, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with toileting hygiene, showering/bathing self, and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) with oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with eating and required supervision or touching assistance with sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depressive disorder (serious illness that negatively affects how one feels, thinks and acts), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of Resident 2's untitled care plan, dated 5/2/2022, the care plan indicated Resident 2 had ineffective coping related to a past traumatic incident, manifested by uncontrollable mood swings causing anger and paranoid thoughts, thinking someone was coming after Resident 2, causing stress. Interventions included to build a trusting relationship during day-to-day activities, encourage group activities, and provide a safe environment and atmosphere of acceptance. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with showering/bathing self. The MDS indicated Resident 2 required partial/moderate assistance with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 3 of 9 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 01/19/2024 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 0603 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene. The MDS indicated Resident 2 required setup or clean up assistance with eating and required supervision or touching assistance with rolling left to right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, toilet transfers, walking 10 feet. 3. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, anxiety disorder, and major depressive disorder. During a review of Resident 3's H&P, dated 6/10/2023, the H&P indicated Resident 3 had the capacity to make decision for activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. The MDS indicated Resident 3 required partial/moderate assistance with showering/bathing self. The MDS indicated Resident 3 required supervision or touching assistance with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 required setup or clean-up assistance with eating. The MDS indicated Resident 3 required supervision or touching assistance with toilet transfers. The MDS indicated Resident 3 required setup or clean-up assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. During a concurrent observation and interview on 1/18/2024 at 9:50 am, while on a tour with the Social Services Director (SSD), two blue utility/linen carts were tied to the hallway siderail and the strike plate hole in front of RM [ROOM NUMBER]'s doorway. The SSD stated two utility carts were blocking RM [ROOM NUMBER]'s doorway. The SSD stated there was a clear trash bag that tied both utility carts together, a clear trash bag that tied the left utility cart to the inside of RM [ROOM NUMBER]'s strike plate hole, and a clear trash bag that tied the right utility cart to the right siderail in the hallway. The SSD stated the SSD was unclear why there were trash bags tying two utility carts in place to block RM [ROOM NUMBER]'s doorway. During a concurrent observation and interview on 1/18/2024 at 9:52 am, with CNA 1, in front of RM [ROOM NUMBER]'s doorway, there were two utility carts blocking the doorway. CNA 1 stated the utility carts were tied with clear trash bags. CNA 1 stated the Residents in RM [ROOM NUMBER] (Residents 1, 2, and 3) could not get out the room unless CNA 1 or another staff member (in general) untied the three trash bags and moved the two utility carts out of RM [ROOM NUMBER]'s doorway. CNA 1 stated the purpose of blocking RM [ROOM NUMBER]'s doorway was to block Resident 1 from coming out of RM [ROOM NUMBER] due to Resident 1's behavioral issues. CNA 1 stated Resident 1 stole other residents' (unidentified) cups and while walking, Resident 1 spilled water on the floor. During an interview on 1/18/2024 at 10:03 am, with Licensed Vocational Nurse (LVN) 1, in front of Resident 1's doorway, LVN 1 stated CNA 1 informed LVN 1 that CNA 1 barricaded (blocked) Resident 1's doorway with two utility carts and tied the carts with trash bags to keep Resident 1 in the room. LVN 1 stated, CNA 1 needed to keep Resident 1 in the room while housekeeping staff (in general) cleaned the floor because Resident 1 spilled liquid from Resident 1's cups all over the floor. LVN 1 stated blocking RM [ROOM NUMBER]'s doorway could lead to injury to Resident 1 in an emergency. During a concurrent observation and interview on 1/18/2024 at 10:11 am, with LVN 2, in front of RM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 4 of 9 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 01/19/2024 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 0603 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [ROOM NUMBER]'s doorway, LVN 2 untied three, clear trash bags anchored to two utility carts in RM [ROOM NUMBER]'s doorway. LVN 2 stated Residents 1, 2, and 3 were in RM [ROOM NUMBER] at the time RM [ROOM NUMBER]'s doorway was blocked. LVN 2 stated Residents 2 and 3 were trapped inside RM [ROOM NUMBER] with Resident 1 and could not get out of the room. LVN 2 stated blocking Residents 1, 2, and 3 in their room was a type of abuse used for staff convenience. During an interview on 1/18/2024 at 10:18 am, Resident 2 stated Resident 2 did not know why staff blocked RM [ROOM NUMBER]'s doorway so Resident 2 could not get out of the room. Resident 2 stated Resident 2 did not like it when staff did that. Resident 2 stated staff were not nice, and it made Resident 2 feel terrible when staff blocked the doorway. Resident 2 stated Resident 2 wished staff would stop blocking the doorway because it did not make sense when he was trapped in the room with Resident 1. Resident 2 stated Resident 2 did not know how to ask for help when Resident 2 wanted to get out of the room or needed assistance. During an interview on 1/18/2024 at 11:38 am, with CNA 1, CNA 1 stated Resident 3 would yell and scream to be let out of the room to smoke cigarettes when the doorway was barricaded. During an interview with CNA 3 on 11/18/2024, at 11:56 am, CNA 3 stated CNA 1 barricaded Resident 1's doorway because housekeeping staff (in general) had to spend time cleaning up whatever Resident 1 dropped on the floor. CNA 3 stated this happened every day. CNA 3 stated when CNA 3 saw RM [ROOM NUMBER]'s doorway barricaded, CNA 3 untied the utility carts, but CNA 3 would get yelled at by other nursing staff (unable to identified). CNA 3 stated barricading Resident 1 inside RM [ROOM NUMBER] was abuse in the form of involuntary seclusion. CNA 3 stated Resident 3 liked to smoke cigarettes and when RM [ROOM NUMBER] was blocked by the utility/linen carts, Resident 3 could not go out to smoke. CNA 3 stated Resident 3 had to yell and scream until staff eventually let Resident 3 out of the room to smoke. During an interview on 1/18/2024 at 12:12 pm, with Resident 3, Resident 3 stated Resident 3 liked to smoke. Resident 3 stated it made Resident 3 really mad and upset because Resident 3 had to yell and scream to get someone to let Resident 3 out of RM [ROOM NUMBER] to smoke. Resident 3 stated it generally took over 15 minutes for staff to let Resident 3 out of the room. Resident 3 stated it felt like staff forget about everyone in RM [ROOM NUMBER]. Resident 3 stated it was stupid Resident 3 had to ask for permission to leave the room and Resident 3 hated it. During an interview on 1/18/2024 at 12:31 pm, with the Infection Prevention Nurse (IPN), the IPN stated the IPN had put the utility carts in RM [ROOM NUMBER]'s doorway before, but never tied the carts with trash bags. The IPN stated this practice (blocking RM [ROOM NUMBER]'s doorway) was done by the IPN and other staff (unidentified) to diminish (reduce) Resident 1's traffic around the facility because Resident 1 walked around the facility with cups of water and spilled the water everywhere. The IPN stated the utility carts were generally put in RM [ROOM NUMBER]'s doorway in the morning when staff were busy. During a concurrent observation and interview on 1/18/2024 at 12:47 pm, with the DON and Admissions Director (AD), the facility's security footage of Camera Two was reviewed. The DON stated on 1/18/2024 at 8:29:14 am, Resident 1 went into RM [ROOM NUMBER]. The DON stated on 1/18/2024 at 8:30:11 am, CNA 1 held a trash bag in CNA 1's hands. The DON stated on 1/18/2024 at 8:31:46 am, CNA 1 moved two utility carts into the doorway of RM [ROOM NUMBER]. During a concurrent interview and record review on 1/18/2024 at 2:49 pm, with LVN 2, Residents 1, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 5 of 9 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 01/19/2024 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 0603 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 2, and 3's AR were reviewed. Residents 1, 2, and 3 had diagnoses of schizophrenia and Residents 2 and 3 had anxiety. LVN 2 stated Residents 1, 2, and 3's schizophrenia could have been exacerbated from being barricaded in RM [ROOM NUMBER]. LVN 2 stated Residents 2 and 3 could have anxiety attacks (intense feeling of dread, fear, or discomfort, with a feeling of losing control or that one's life is in danger when no threat is present) and pass out. LVN 2 stated staff would not know if a medical emergency (illness or injuries that need care right away) was happening in RM [ROOM NUMBER] because the residents (Residents 1, 2, and 3) were barricaded inside. During an interview on 1/16/2024 at 3:18 pm, with the DON, the DON stated the utility carts were supposed to be used for linens, towels, and blankets for the residents. The DON stated utility carts were to be stored in the hallways along the walls. The DON stated the utility carts were not supposed to be used to block RM [ROOM NUMBER]'s doorway and barricade Residents 1, 2, and 3 inside their room. The DON stated doing so was abuse in the form of involuntary seclusion. The DON stated Residents 1, 2, and 3 who were involuntarily secluded to their rooms were at risk for depression, anxiety, and negative behaviors. The DON stated Residents 1, 2, and 3 who had diagnoses such as schizophrenia, depression, and anxiety were at higher risk of having an exacerbation of their illness symptoms by being involuntarily secluded in their room. The DON stated Residents 1, 2, and 3 could become entangled by the barricade and become injured or die when Residents 1, 2, and 3 attempt to get out. During a review of the facility's policy and procedure (PP) titled, Involuntary Seclusion, undated, the PP indicated the goal was to ensure all residents would be free of involuntary seclusion. The PP indicated examples of involuntary seclusion included confining a resident to his or her room as form of punishment or for staff convenience, and any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. The PP indicated secluding or confining a resident against his or her will was prohibited. During a review of the facility's PP titled, Resident Rights, revised 2/2021, the PP indicated employees shall treat all residents with kindness, respect, and dignity. The PP indicated residents had the right to be free from involuntary seclusion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 6 of 9 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 01/19/2024 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement the care plan (CP) for one of 10 sampled residents (Resident 1) when Resident 1 was walking around the facility, spilling liquid on the floor. This failure resulted in Certified Nurse Assistant (CNA) 1 barricading (improvised barrier erected to prevent or delay of movement of residents getting through) Residents 1 ' s doorway with two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one trance and exit). This deficient practice had the potential for Residents 1 to experience further incidents of involuntary seclusion that could lead to psychosocial (mental, emotional, social, and spiritual effects) harm, serious injury, serious harm, serious impairment, or death. (Cross reference F603) Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (serious mental illness in which people interpret reality abnormally), unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and obsessive-compulsive personality disorder (a pervasive obsession with order, perfectionism, control, and specific ways of doing things). During a review of Resident 1 ' s untitled CP, revised on 2/21/2020, the CP indicated Resident 1 had episodes of wandering in co-residents ' rooms. The CP indicated interventions of maximizing Resident 1 ' s abilities to participate in activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself) by encouraging exercise, movement, social interaction, and arts and crafts; minimizing the effects of environmental stress, safety hazards, and disorientation through creation of calm, reassuring and safe environment; and re-directing resident to Resident 1 ' s room or group activities when Resident 1 was observed attempting to enter co-residents ' room. During a review of Resident 1 ' s untitled CP, revised on 2/21/2020, the CP indicated Resident 1 had non-compliance manifested by grabbing food/drinks from the trays of other residents. The CP indicated interventions to redirect Resident 1; inform Resident 1 of possible alternatives, consequences/needs; document Resident 1 ' s response to specific non-compliance as needed; notify any risk/consequences in result of non-compliance; respect Resident 1 ' s rights; provide explanation/rationale for care for better compliance; and involve Resident 1 ' s significant other to gain cooperation. During a review of Resident 1 ' s History and Physical (H&P), dated 2/19/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated 11/17/2023, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 required supervision or touching assistance with sitting to lying, lying to sitting on side of bed, sit to stand, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 7 of 9 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 01/19/2024 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 chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/18/2024 at 9:50 am, while on a tour with the Social Services Director (SSD), two blue utility/linen carts were tied to the hallway side rail and the strike plate hole in front of Resident 1 ' s doorway. The SSD stated the two utility carts were blocking Resident 1 ' s doorway. The SSD stated there was a clear trash bag that tied both utility carts together, a clear trash bag that tied the left utility cart to the inside of Resident 1's strike plate hole, and a clear trash bag that tied the right utility cart to the right side rail in the hallway. The SSD stated the SSD was unclear why there were trash bags tying two utility carts in place to block Resident 1 ' s doorway. Residents Affected - Few During a concurrent observation and interview on 1/18/2024 at 9:52 am, with CNA 1, in front of RM [ROOM NUMBER] ' s doorway, there were two utility carts blocking the doorway. CNA 1 stated the utility carts were tied with clear trash bags. CNA 1 stated the Residents in RM [ROOM NUMBER] (Residents 1, 2, and 3) could not get out the room unless CNA 1 or another staff member (in general) untied the three trash bags and moved the two utility carts out of Resident 1 ' s doorway. CNA 1 stated the purpose of blocking Resident 1 ' s doorway was to block Resident 1 from coming out of Resident 1 ' s room due to behavioral issues. CNA 1 stated Resident 1 stole other residents ' (unidentified) cups and while walking, Resident 1 would spill water on the floor. During an interview on 1/18/2024 at 10:03 am, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 ' s care plan interventions were to redirect Resident 1, turn Resident 1 ' s television on to sports, and activities with close supervision. LVN 1 stated Resident 1 ' s care plans interventions were not implemented before Resident 1 was barricaded in the room. During a concurrent interview and record review on 1/18/2024 at 10:39 am, with LVN 2, Resident 1 ' s untitled CPs were reviewed. LVN 2 stated none of Resident 1 ' s CP interventions were used before staff barricaded Resident 1 inside Resident 1 ' s room with utility carts and trash bags. LVN 2 stated the CP interventions should be followed for resident safety. LVN 2 stated if staff and LVN 2 followed Resident 1 ' s CP interventions, they would not have needed to barricade Resident 1 in the room. During an interview on 1/16/2024 at 3:18 pm, with the DON, the DON stated CPs (in general) were made for residents with specific problems and the interventions needed to be followed at all times by the staff (in general). The DON stated if CP interventions were not working, the CP needed to be revised and addressed with upper staff like the Interdisciplinary Team (IDT- team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) so problems could be addressed. The DON stated if staff had followed Resident 1 ' s CP, Resident 1 would not need to be barricaded in the room. The DON stated utility carts were not supposed to be used to block residents ' room doorway and barricade residents inside their rooms. The DON stated doing so was abuse in the form of involuntary seclusion. The DON stated residents who were involuntarily secluded to their rooms were at risk for depression, anxiety, and negative behaviors. The DON stated involuntary secluding residents who had diagnoses such as schizophrenia, depression, and anxiety were at higher risk of having an exacerbation of their illness symptoms. The DON stated residents could become entangled by the barricade and become injured or die while attempting to get out of the room. During a review of the facility ' s policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the PP indicated a comprehensive, person-centered CP included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 8 of 9 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 01/19/2024 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete measurable objectives and timetables to meet the residents ' physical, psychosocial and functional needs was developed and implemented for each resident. The PP indicated CP interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the residents ' problem areas and their causes, and relevant clinical decision making. The PP indicated, when possible, interventions addressed the underlying source(s) of the problem area(s), not just symptoms or triggers. The PP indicated assessments of residents are ongoing and CP are revised as information about the residents and the residents ' conditions change. The PP indicated the IDT reviewed and updated the CP when the desired outcome was not met. Event ID: Facility ID: 555106 If continuation sheet Page 9 of 9