Health inspection·March 7, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few placed under Bioethics Committee of the facility as the legal decisionmaker for Resident 1 since Resident 1's readmission to the facility from the hospital in 2021. AC 1 stated there were no signed documentation regarding Resident 1's legal decisionmaker during the period from 2021 - 2023. During an interview and a concurrent review of Resident 1's records on [DATE] at 3:03 PM with MDS nurse 1 (MDSN 1), Resident 1's IDT notes, AR, and H&P were reviewed. MDSN 1 stated Resident 1 had severe impairment in cognition (ability to understand and process information). MDSN 1 stated Resident 1 was self-responsible per AR. MDSN 1 stated at least 3 department heads must attend the IDT meetings for Resident 18. MDSN 1 stated the following regarding quarterly IDT meetings: 1. On [DATE] - attended by MDSN 1 (licensed vocational nurse), Activity Director 1 (AD 1), and Social Services Director (SSD 1) 2. On [DATE]- attended by MDSN 1 (licensed vocational nurse), SSD 2 3. On [DATE] - attended by MDSN 1 (licensed vocational nurse), SSD 2, Dietary Supervisor (DS) 4. On [DATE] - attended by MDSN 1 (licensed vocational nurse), SSD 2, DS During an interview on [DATE] at 3:14 PM, the Director of Nursing (DON) stated for residents without decision-making capacity and without any resident representative, the IDT must assess and evaluate the resident's medical needs and interventions at least quarterly and as needed, such as whenever there are changes in condition, to determine whether to continue with the plan of care or make changes. The DON stated the IDT must be comprised of the MD, RN responsible for the resident, RP, and other appropriate staff, such as activities staff, social services staff, and/or rehab staff. The DON stated the IDT must have a meeting to discuss the plan of care for the resident. The DON stated the MD and RN must be present to assess the resident. The DON stated it was important to coordinate the plan of care to ensure proper care interventions would be implemented for the resident. During a review of the facility's undated policy and procedures (P&P 1), titled Lack of Capacity: When Medical Intervention(s) Require Informed Consent, P&P 1 indicated the following: 1. An IDT review of prescribed medical intervention(s) must be provided when the resident lacks the capacity and there is no person with legal authority to make healthcare decisions on behalf of the resident. 2. The IDT must include the resident's attending physician, an RN with responsibility for the resident, a resident representative, and other appropriate staff. 3. The resident representative may include a family member, a friend, who is unable to take full responsibility for the health care decisions of the resident, but has agreed to serve on the IDT, or another person authorized by the state or federal law (Ombudsman). 4. The IDT must periodically evaluate the use of the prescribed medical intervention at least quarterly or upon a significant change in the resident's medical condition. 5. The IDT review must include the following: a. Review of the physician's assessment of the resident's condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 2 of 40 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 03/07/2024 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 0553 b. Reason for the proposed use of the medical intervention. Level of Harm - Minimal harm or potential for actual harm c. Type of medical intervention to be used in the resident's care, including its probable frequency and duration. Residents Affected - Few d. Probable impact on the resident's condition, with and without the use of medical intervention. e. Reasonable alternative medical interventions considered or utilized and reasons for their discontinuance or inappropriateness. During a review of the facility's policy and procedures (P&P 2), titled Bioethics Committee (undated), P&P 2 indicated the following: 1. The Bioethics Committee must assist in resolving conflicts regarding bioethics issues in areas of confusion and uncertainty. 2. The Bioethics Committee has an active duty, as healthcare providers, to proceed based upon the established principles of bioethics and particularly, the foundational principles of autonomy, beneficence, non-maleficence, and justice. 3. The Bioethics Committee may consist of some or all of the following: Administrator, DON or Registered Nurse designee, Medical Director, Attending Physician, Social Services Designee, and any other party deemed necessary or who would be helpful to aid in the discussion of the issue(s) at hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 3 of 40 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 03/07/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of one sampled resident's (Resident 11) physician was notified of the development of a rash on Resident 11's left and right buttocks. This deficient practice had the potential to result in a delay in treatment and/or services and could result in a physical decline to Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and schizophrenia (a mental disorder effecting how a person thinks and feels). During a review of a History and Physical (H&P), dated 1/19/24, the H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of a MDS, dated [DATE], indicated Resident 11 was dependent (helper does all the effort) with eating, oral hygiene, toilet hygiene, showers, upper and lower body dressing, personal hygiene, and required substantial to maximal assistance (helper does more than half of the effort) with rolling left to right, sit to lying and lying to sit positions. During a review of Resident 11's care plan (summary of a person's health conditions, specific care needs, and current treatments) titled At Risk for Skin Breakdown secondary to skin incontinence, initiated 3/27/19 and revised 1/2/20, the care plan's interventions indicated to notify physician of significant changes. The care plan's focus or interventions did not indicate or address the skin concerns on Resident 11's left and right buttocks. During an interview with Certified Nursing Assistant 4 (CNA 4) on 3/5/24 at 9:36 a.m., CNA 4 stated Resident 11's butt (left and right buttocks) had a rash for a few days. CNA 4 stated CNA 4 was instructed to put barrier cream during adult brief changes. During an interview with CNA 3 on 3/5/24 at 12:46 p.m., CNA 3 stated Resident 11 had a rash on her butt for a few days. CNA 3 stated CNA 3 did not remember if CNA 3 informed a nurse regarding the rash, but CNA 3 was instructed to apply barrier cream on the area. During an interview and concurrent observation with Licensed Vocational Nurse 1 (LVN 1) on 3/5/24 at 12:49 p.m., LVN 1 stated there were two big patches and generalized small patches on Resident 11's left buttock and one big patch and small scattered patches on Resident 11's right buttock. LVN 1 stated LVN 1 was aware of Resident 11's skin condition for two days. LVN 1 stated LVN 1 did not know if Resident 11's physician was notified of the newly developed skin condition on Resident 11's buttocks. LVN 1 stated it was important to inform the resident's physician [for Resident 11] to get proper treatment to prevent worsening [of the rash] or development of pressure injuries (bed sores, are an injury to the skin and underlying tissue). During an interview and concurrent record review with the Director of Nursing (DON) on 3/5/24 at 1:25 p.m., Resident 11's paper and electronic medical record (chart) was reviewed. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 4 of 40 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 03/07/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no documentation [that indicated] Resident 11's physician was informed of Resident 11's rash located on Resident 11's left and right buttocks. During an observation and concurrent interview, inside Resident 11's room with the DON on 3/5/24 at 2:06 p.m., the DON stated Resident 11 first layer of skin on the left and right buttocks area were not there. The DON stated Resident 11 had moist non-oozing patches of redness on the left and right buttocks. The DON stated Resident 11's bilateral buttocks were not normal. The DON stated Resident 11's physician should have been informed of Resident 11's possible skin condition and be informed of what was going on with Resident 11. During an interview and concurrent record review of Resident 11's paper and electronic chart on 3/5/24 at 2:49 p.m., LVN 1 stated there was no documentation [that indicated] Resident 11's physician was informed regarding Resident 11's skin condition on Resident 11's buttocks. LVN 1 stated LVN 1 was not aware if the physician was informed and stated, the physician should have been notified for Resident 11 to get proper treatment and prevent the development of pressure injuries. During an interview and concurrent record review of Resident 11's paper and electronic chart with Minimum Data Set Nurse (MDSN 1), on 3/6/24 at 2:17 p.m., MDSN 1 stated there was no documentation prior to 3/5/24 that indicated Resident 11's physician was not informed of Resident 11's skin issues on Resident 11's buttocks. MDSN 1 stated Resident 11's physician should have been notified for orders to be carried out. During an interview with Resident 11's Physician's Assistant for Wounds 1 (PA 1) on 3/6/24 at 4:27 p.m., PA 1 stated the first time PA 1 was informed of Resident 11's skin issues was on 3/5/24. PA 1 stated PA 1 would have liked to have been informed of the newly developed skin issue to prepare a treatment plan specifically for Resident 11. During an interview with the DON on 3/7/24 at 11:12 a.m., the DON stated the DON was not aware of Resident 11's skin condition on Resident 11's bottom area until 3/5/24. The DON stated Resident 11 was dependent with toilet hygiene and skin irritation could occur. The DON stated it was important for Resident 11's physician to be informed for proper treatment to be done. During a review of the facility's undated polity and procedure (P&P) titled Alteration in Skin Integrity, indicated residents with alteration in skin integrity will be assessed, orders for treatment will be obtained and care plans will be developed. Physician will be notified, and appropriate orders obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 5 of 40 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 03/07/2024 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, notice of liability) and Notice of Medicare Non-Coverage (NOMNC) letters/forms to one of one sampled resident (Resident 196) three days prior to Resident 196's last day covered as indicated in the facility's policy and procedure (P&P), titled, Understanding Medicare Denial Letters,. Residents Affected - Few This deficient practice had the potential to result with Resident 196 to not be aware of possible charges for services rendered that were not covered after the last Medicare coverage day. Findings: During a review of Resident 192's admission Record (AR), the AR indicated Resident 192 was admitted to the facility 6/27/23 and readmitted [DATE] with diagnoses that included lack of coordination, muscle weakness, and abnormalities of gait (walk). During a review of the Minimum Data Set (MDS, an assessment and screening tool), dated 12/28/23 the MDS indicated Resident 192's cognition (ability to understand and process information) was intact. During an interview and concurrent record review of Resident 196's SNFABM with the Business Office Manager (BOM) on 3/6/24 at 10:11a.m., the SNFABM indicated Resident 192's last day of Medicare coverage ended on 9/8/24. The SNFABM indicated starting on 9/9/24, Resident 196 may have to pay out of pocket for skilled services if Resident 196 did not have another insurance to cover the costs. The SNFABM indicated Resident 196 signed the document on 9/8/24. The BOM stated Resident 196 needed to [be given] enough time to appeal and continue with services if they (the resident) did not agree to pay out of pocket. During an interview with the BOM on 3/6/24 at 10:35 p.m., the BOM stated the facility did not have policy regarding beneficiary notices. The BOM stated the facility followed Medicare (a federally ran health insurance agency for people 65 and older) guidelines. The BOM stated Residents (in general) should be given at least a three-day notice prior to the skilled services ending. The BOM stated it was important to give residents a three-day notice because if they did not agree, Resident 196 [could practice] Resident 196's right to appeal. During a review of the facility's untitled P&P, titled Understanding Medicare Denial Letters, the P&P indicated the document was intended as a step-by-step guide to help understand Medicare Denial Letters. Step 2 of the P&P indicated three days prior to discharge from Medicare services, fill out the Skilled Nursing Facility Determination on Continued Stay, in the reason section, explain in language that the resident/responsible party can understand why the resident no longer qualifies for Medicare coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 6 of 40 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 03/07/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to ensure a comprehensive assessment of the functional limitation in range of motion (ROM, full movement potential of a joint [where two bones meet]) of one of two sampled residents (Resident 18) with mobility and ROM limitations, was complete and accurate. This failure had the potential to lead to Resident 18's worsened contractures and increased risks for pain and skin breakdown related to incorrect treatments and plan of care. Cross reference with F688 and F657 Findings: A. During a review of Resident 18's admission Record (AR), the AR indicated the facility admitted Resident 18 on 10/19/2023 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), syncope (fainting) and collapse, anxiety disorder (persistent and excessive worry that interferes with daily activities), and generalized muscle weakness. During a review of Resident 18's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/6/2023, the MDS indicated Resident 18 had severely impaired cognitive skills (ability to think, pay attention, process information, and remember) for daily decision making. The MDS indicated Resident 18 required substantial/maximal assistance with most self-care activities and mobility. During a review of Resident 18's Physical Therapy (PT, healthcare profession that uses exercises and physical activities to help condition muscles and restore or maintain strength and movement) Evaluation & Plan of Treatment (PTEPT), dated 10/20/2023, the PTEPT indicated both of Resident 18's lower extremities ROM were impaired. During an interview and concurrent review on 3/7/2024 at 2:37 PM with MDS nurse 1 (MDSN 1), Resident 18's MDS assessment, PTEPT, and Resident Assessment Instrument (RAI) User's Manual (official guidelines when conducting MDS assessments) were reviewed. MDSN 1 stated Resident 18's functional limitation in ROM (limited ability to move a joint that interferes with daily functioning, particularly with activities of daily living, or places the resident at risk of injury), MDSN 1 coded no impairment for Resident 18's lower extremities (hip, knee, ankle, and foot). MDSN 1 stated he did not review the rehab notes when he conducted the MDS assessment, dated 12/6/2023. MDSN 1 stated he would submit the MDS correction to accurately reflect Resident 18's condition. MDSN 1 stated an accurate MDS assessment was necessary to ensure an accurate plan of care for the resident. During an interview on 3/7/2024 at 3:42 PM, the Director of Nursing (DON) stated a resident's impairment on both lower extremities must be assessed and documented properly to ensure a consistent plan of care, such as ROM or mobility training of the affected extremities was implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 7 of 40 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 03/07/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedures (P&P), titled Resident Assessment (undated), the P&P indicated the following: 1. Sources of information to complete the MDS include review of resident's record, communication with the resident, family, health provider, and physician, and observation of the resident. Residents Affected - Few 2. The comprehensive assessment must be used to develop a comprehensive care plan to allow the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning. 3. Health care professionals completing portions of the MDS must certify the accuracy of the section(s) they have completed by entering the signature, title, date completed, and the section(s) completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 8 of 40 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 03/07/2024 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 - 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** b. During a review of Resident 11's AR, the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and schizophrenia (a mental disorder effecting how a person thinks and feels). During a review of a History and Physical (H&P), dated 1/19/24, the H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of a MDS, dated [DATE], indicated Resident 11 was dependent (helper does all the effort) with eating, oral hygiene, toilet hygiene, showers, upper and lower body dressing, personal hygiene, and required substantial to maximal assistance (helper does more than half of the effort) with rolling left to right, sit to lying and lying to sit positions. During an interview with Certified Nursing Assistant 4 (CNA 4) on 3/5/24 at 9:36 a.m., CNA 4 stated Resident 11's butt (left and right buttocks) had a rash for a few days. During an interview with CNA 3 on 3/5/24 at 12:46 p.m., CNA 3 stated Resident 11 had a rash on her butt for a few days. During an interview and concurrent observation with Licensed Vocational Nurse 1 (LVN 1) on 3/5/24 at 12:49 p.m., LVN 1 stated there were two big patches and generalized small patches on Resident 11's left buttock and one big patch and small scattered patches on Resident 11's right buttock. LVN 1 stated LVN 1 was aware of Resident 11's skin condition for two days. During an interview and concurrent record review with the Director of Nursing (DON), on 3/5/24 at 1:25 p.m., Resident 11's paper and electronic medical record was reviewed. The DON stated there was no documentation [that indicated a] care plan was developed to address Resident 11's skin condition [rash] on Resident 11's buttocks area. During an interview and concurrent record review of Resident 11's paper and electronic chart on 3/5/24 at 2:49 p.m., LVN 1 stated there was no documentation [that indicated] a care plan [was created] for Resident 11's skin. During an interview and concurrent record review of Resident 11's paper and electronic chart with Minimum Data Set Nurse (MDSN 1), on 3/6/24 at 2:17 p.m., MDSN 1 stated there was no documentation prior to 3/5/24 that indicated a care plan regarding [a rash on] Resident 11's buttocks [was created]. MDSN 1 stated care plans were important to have a continuous plan of the resident's (in general) care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/22, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P indicated, Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P indicated, Assessments of residents are ongoing and care plans are revised as information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 9 of 40 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 03/07/2024 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 about the residents and the residents' conditions change. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop comprehensive person-centered care plans for two of two sampled residents (Residents 15 and 11) when: Residents Affected - Some a. For Resident 15, The facility failed to develop a care plan that included interventions to address Resident 15's urinary incontinence (loss of bladder control). b. For Resident 11, the facility failed to develop a care plan that included goals and interventions to address Resident 11's rash located on Resident 11's left and right buttocks. This failure had the potential to result in unmet individualized needs for Residents 15 and 11 and the potential to affect the resident's physical and psychosocial well-being. (Cross reference F690 and F580) Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/18/24, the MDS indicated Resident 15 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 15 required partial to moderate (helper does less than half the effort) assistance from staff for toileting, dressing, and bathing. The MDS indicated Resident 15 was incontinent of urine. During an interview on 3/6/24 at 10:17 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 15 was incontinent of urine. During a concurrent interview and record review on 3/6/24 at 1:50 p.m. with the MDS Nurse (MDSN), Resident 15's care plans were reviewed. MDSN stated Resident 15 did not have a care plan addressing Resident 15's urinary incontinence. MDSN stated the staff should create a care plan for Resident 15's incontinence so staff knew what interventions were needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 10 of 40 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 03/07/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 18's AR, the AR indicated the facility originally admitted Resident 18 on 10/19/23 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), syncope (fainting) and collapse (fall down), anxiety disorder (persistent and excessive worry that interferes with daily activities), and generalized muscle weakness. During a review of Resident 18's H&P, dated 10/21/23, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's MDS, dated [DATE], MDS indicated Resident 18 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 18 required substantial to maximal assistance with most self-care activities and mobility. During a review of Resident 18's Order Summary Report (OSR) with active orders as of 2/1/24, the OSR indicated the following physician orders: Order dated 12/4/23 - Restorative Nursing Aide (RNA, certified nursing aide who helps residents maintain their function and joint mobility) to apply B knee splints and L ankle splint 2-4 hours daily 7 times per week as tolerated. During a review of Resident 18's CPs, the CPs indicated the following: 1. CP 1 initiated on 1/3/23 - RNA to apply B knee splints for 3-4 hours or as tolerated daily 7 times per week to preserve skin and joint integrity. 2. CP 2 initiated on 1/3/23 - RNA to apply L ankle PRAFO for 3-4 hours daily 7 times per week as tolerated. During an interview and a concurrent record review on 3/7/2024 at 10:15 a.m., with the Director of Rehab (DOR), Resident 18's care plans were reviewed. The DOR indicated Resident 18's care plans were not updated [to reflect] physician's orders. The DOR stated not updating Resident 18's care plans could lead to inconsistent care provided to Resident 18. During a review of the facility's policy and procedures (P&P), titled The Resident Care Plan (undated), the P&P indicated the following: 1. The objective of the care plan is to provide an individualized nursing care plan and to promote continuity of resident care. 2. The nursing care plan acts as a communication instrument between nurses and other disciplines. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 11 of 40 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 03/07/2024 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 0657 contains information of importance for all nurses concerning nursing approach and problem solving. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Some The Director of Nursing (DON) is responsible for ensuring that each professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems of the resident, and the goals or objectives of the plan. 4. The licensed nurse is responsible for ensuring that the plan of care is initiated and evaluated. Reassessment must be conducted, and care plan must be changed as needed to reflect the resident's current status. 5. Meetings shall be held thereafter as often as necessary to keep the plan current and effective. The residents plan of care shall be reviewed at least quarterly. Based on interview and record review, the facility failed to review and revise comprehensive care plans for two of two sampled residents (Residents 41 and 18) by failing to: a. For resident 41, the facility failed to review the comprehensive care plan for falls, as indicated in the facility's policy and procedure (P&P), titled, Initial Fall Risk Assessment. b. For Resident 18, the facility failed to ensure bilateral knee extension splints (B knee splints, material used to extend or straighten the knees as much as possible) and left ankle pressure-relieving ankle foot orthosis (L PRAFO, device to maintain foot/ankle stability while in bed) care plans (CPs) for Resident 18, who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility limitations, were in accordance with the physician's orders. This failure had the potential to result in unmet individualized needs for Residents 41 and 18 due to outdated inadequate interventions and had the potential to result in a decline in the residents' physical and psychosocial well-being. (Cross reference with F688, F689, and F636) Findings: a.During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 12 of 40 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 03/07/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/23/23, the MDS indicated Resident 41 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 41 was dependent (helper does all the effort) on staff for bathing. The MDS indicated resident 41 required substantial to maximal assistance (helper does more than half the effort) from staff for toileting and dressing. The MDS indicated Resident 41 had one fall with major injury (bone fractures, joint dislocations, closed head injuries, with altered consciousness, subdural hematoma) at the facility. During a concurrent interview and record review on 3/7/24 at 12:50 p.m. with the Director of Nursing (DON), Resident 41's care plan titled, Superstar Star ., initiated 1/21/22, revised 8/14/23, the care plan indicated Resident 41 was at risk of falling and/or injury secondary to, balance deficit, cognitive impairment, and poor safety awareness. The DON stated the care plan was created because Resident 41 was at high risk of falling. The DON stated if the quarterly fall risk assessment indicated Resident 41 was at high risk of falling, then the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) needed to review the care plan to determine if the interventions were still appropriate to reduce or prevent Resident 41 from falling. The DON stated Resident 41's medical record did not indicate the IDT was meeting quarterly to review Resident 41's fall risk interventions. The DON stated the IDT could have implemented new interventions if they met quarterly and reviewed the current interventions. During a review of the facility's P&P titled, Initial Fall Risk Assessment, undated, the P&P indicated, The plan of care will be reviewed by the IDT quarterly and as needed for update of the resident's current needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 13 of 40 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 03/07/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility staff failed to administer Simbrinza 1% 2% (brinzolamide/brimonidine tartrate, eye drops to treat glaucoma [progressive eye disease causing vision loss and blindness due to the damage to the optic nerve]), in accordance with the professional standards of practice to one of one sampled resident (Resident 7), who was selected for medication administration observation. Residents Affected - Few This failure had the potential to result in worsened vision to Resident 7 due to decreased medication efficacy (ability of the medication to produce the maximal desired effect) due to the systemic absorption of the eye drops and/or subtherapeutic dose (concentration of a drug lower than what is usually prescribed to treat a disease effectively). Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility initially admitted Resident 7 on 2/4/2010 with multiple diagnoses including glaucoma, cataract (clouding of the eye lens causing cloudy, blurry, or unclear vision), astigmatism (imperfection of eye curvature causing blurred vision), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and hypertension (high blood pressure). During a review of Resident 7's History and Physical (H&P), dated 3/10/23, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/4/24, the MDS indicated Resident 7 had severely impaired cognition (ability to understand and process information). During a review of Resident 7's Order Summary Report (OSR), active orders as of 3/6/24, the OSR indicated a physician's order, dated 1/15/2018, the order indicated to administer Simbrinza Suspension 1% - 0.2% 1 eye drop in both eyes three times a day for glaucoma. During the medication administration observation on 3/6/24 at 11:48 a.m., Licensed Vocational Nurse 1 (LVN 1) administered Simbrinza to the middle of the right eye, then immediately to the middle of the left eye. Resident 7 squeezed her eyes shut after the left eye drop administration, causing minimal eye drop solution to come out of the left eye. LVN 1 did not apply pressure to the inner corners of both eyes after eye the drops were administrated. During an interview on 3/6/24 at 11:54 a.m., LVN 1 was unable to state proper eye drop administration technique to ensure maximal absorption of the eye drops. During an interview on 3/7/24 at 3:14 p.m., the Director of Nursing (DON) stated the proper eye drop procedures included administering the eye drop to the lower eyelid sac and applying pressure to the lacrimal ducts (tear duct-tube) to prevent systemic absorption of the eye drops and maximize the effect of the eye drops. The DON stated incorrect eye drop administration could lead to decreased medication efficacy. During a review of the facility's policies and procedures (P&P), titled Installation of Eye Drops, dated 3/2023, the P&P indicated the following eye drop procedures: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 14 of 40 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 03/07/2024 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 0658 1. Level of Harm - Minimal harm or potential for actual harm If the resident is sitting up, tilt his/her head backward slightly. 2. Residents Affected - Few Gently pull the lower eyelid down and instruct the resident to look up. 3. Drop the medication into the mid-lower eyelid and then recap the bottle. 4. Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. 5. Gently dry the eyelid with tissue if dripping occurs. During a review of the guidance from the American Academy of Ophthalmology (AAO), titled How to Put in Eye Drops, dated 5/5/23, indicated the following: 1. Whether eye drops are used for glaucoma, dry eye, or eye infection, the eye drops must be used correctly to get the full benefit. 2. Use one hand to pull the lower eyelid down, away from the eye, to form a pocket to catch the drop. 3. Without letting the eye drop bottle to touch the eye or eyelid to prevent contamination, gently squeeze the bottle to let the eye drop fall into the pocket. 4. Apply gentle pressure to the tear ducts, where the eyelids meet the nose for a minute or two-or as long as the ophthalmologist recommends-before opening the eyes to give the eye drop time to be absorbed by the eye, instead of draining into the nose. [Source: https://www.aao.org/eye-health/treatments/how-to-put-in-eye-drops] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 15 of 40 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 03/07/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 one sampled resident (Resident 9) was provided a communication tool or resources to effectively communicate Resident 9's needs when Resident 9 spoke Cantonese (a Chinese dialect). Residents Affected - Few This deficient practice had the potential to result in Resident 9's needs not effectively conveyed to facility staff which could lead to a decline in Resident 9's physical and psychosocial well-being. Findings: During a review of an admission Record (AR), the AR indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses that included anemia (a deficiency when the body does not have enough iron) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 9's care plan (CP), titled Language Barrier: Vietnamese speaking, non-English speaking, initiated 6/6/16 and revised on 5/24/21, the CP's interventions indicated the facility would provide Vietnamese speaking staff to make sure activities needs were met. During a review of Resident 9's CP titled Inability to understand and utilize call light, initiated 3/9/23, the CP's interventions indicated to utilize a communication board when assisting with Resident 9's needs. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/9/24, indicated Resident 9's preferred language was Cantonese, and Resident 9 had adequate (no difficulty) hearing and was rarely/never understood. The MDS indicated indicted Resident 9 needed supervision for touching assistance with sit to lying (moves from lying flat to sitting in bed) and sit to standing (sting in a chair to standing). During an observation and an attempted interview with Resident 9 in Resident 9's room on 3/4/24 at 11:31 a.m., Resident 9 smiled, nodded her head, and did not respond to questions asked in English. There was no communication tool or board observed in the Resident 9's room. During a telephone interview with Resident 9's Family Member (FM 1), on 3/4/24 at 4 p.m., FM 1 stated Resident 9 communicated in Cantonese and did not speak English and FM 1 had never seen the facility use a communication board to communicate with Resident 9. FM 1 stated it [the communication board] would be beneficial and FM 1 would like for someone [the facility] to communicate with Resident 9 in Cantonese because that would help her a lot when she understands the staff. During an observation and concurrent interview with Certified Nurse Assistant 3 (CNA 3) on 3/5/24 at 12:34 p.m., CNA 3 stated Resident 9 did not speak English and spoke a Chinese. CNA 3 stated CNA 3 did not speak Chinese and communicated with Resident 9 through gestures. CNA 3 did not attempt to use the newly placed communication tool located at Resident 9's bedside. During an observation and concurrent interview in Resident 9's room with Licensed Vocational Nurse 2 (LVN 2) on 3/6/24 at 12:05 p.m., stated LVN 2 communicated with Resident 9 by gestures and LVN 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 16 of 40 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 03/07/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not speak Chinese. LVN 2 stated it was important to communicate with Resident 9 because the Resident 9 had rights and [the facility] needed to know what Resident 9's needs were. During an interview with the Minimum Data Sheet Nurse (MDSN 1) on 3/6/24 at 2:18 p.m., MDSN 1 stated it was important to communicate with Resident 9 in Resident 9's language [because no communication can lead] to anxiety, comfort and for [the facility] to know what the resident's needs were. During a review of the facility's undated policy and procedure (P&P) titled, Accommodation of Needs Related to Communication, the P&P indicated the facility will take reasonable steps to ensure the staff will communicate with residents to accommodate the need of residents. The P&P indicated to assign staff to residents who speak the same language if possible and provide communication boards with written translation as indicated. A review of the facility's undated P&P titled Accommodation of Needs, indicated residents will receive services in this facility with reasonable accommodation of individual needs are preferences. Efforts will be made to individualize the resident's environment. The staff will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 17 of 40 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 03/07/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 18) with limited mobility or range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: A. Ensure an accurate assessment of Resident 18's ROM on both upper extremities (BUEs) on 10/20/2023. B. Properly assess Resident 18's tolerance to the right elbow extension splint (R elbow splint, material used to extend or straighten the elbow as much as possible) after the resident readmitted to the facilltiy on 10/19/2023. C. Ensure the order for the Restorative Nursing Aide (RNA, certified nursing aide who helps residents maintain their function and joint mobility) to apply the splints to both knees (B knees) and left ankle (L ankle), dated 12/4/2023, was in accordance with Resident 18's tolerance to splints upon discharge from rehab therapy. These failures had the potential to cause a further decline in Resident 18's mobility and ROM with worsened contractures (chronic joint stiffness) and increased risk for skin breakdown and pain. Cross Reference with F636 and F657 Findings: A. During a review of Resident 18's admission Record (AR), the AR indicated the facility admitted Resident 18 on 10/19/2023 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), syncope (fainting) and collapse, anxiety disorder (persistent and excessive worry that interferes with daily activities), and generalized muscle weakness. During a review of Resident 18's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/6/2023, the MDS indicated Resident 18 had severely impaired cognitive skills (ability to think, pay attention, process information, and remember) for daily decision making. The MDS indicated Resident 18 required substantial/maximal assistance with most self-care activities and mobility. During a review of Resident 18's Order Summary Report (OSR) for 3/2024, the OSR indicated a physician's order, dated 12/4/2023, for RNA to perform passive ROM exercises (PROM, movement of joint through the ROM with no effort from the person) to BUEs daily 7 times per week as tolerated. During a concurrent observation and interview on 3/7/2024 at 9:42 AM with RNA 1, Resident 18 was lying in bed while RNA 1 performed PROM exercises. RNA 1 was unable to bend (flex) the L elbow from an extended position. RNA 1 removed the R elbow splint and stated Resident 18 has more mobility on this side. Resident 18 was able to bend the R elbow up to 90 degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 18 of 40 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 03/07/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and a concurrent review of Resident 18's records on 3/7/2024 at 10:54 AM with Occupational Therapist 1 (OT 1, healthcare professional who aims to increase or maintain a resident's capability to participate in activities of daily living (ADLs, occupations), Resident 18's OT Evaluation & Plan of Treatment (OTEPT), dated 10/20/2023, and Joint Mobility Screening (JMS), dated 10/20/2023, were reviewed. OT 1 stated Resident 18's OTEP, which OT 1 conducted, indicated Resident 18's right upper extremity (RUE) ROM was normal or within functional limits while Resident 18's left upper extremity (LUE) ROM was impaired. In contrast, OT 1 stated Resident 18's JMS, which OT 1 conducted, indicated Resident 18's left elbow had minimal (less than 25% loss in joint mobility) while Resident 18's right elbow had moderate (26% - 50% loss in joint mobility). OT 1 stated Resident 18's JMS indicated Resident 18's RUE ROM was more severe than the LUE ROM. OT 1 was unable to explain the conflicting assessments of Resident 18's RUE and LUE. OT 1 stated, There was something about the resident's [Resident 18's] left side that made me focus on that side [LUE] more. During a concurrent observation and interview on 3/7/2023 at 11:23 AM with OT 1, Resident 18 was lying in bed when OT 1 assessed the current ROM of BUEs. OT 1 was able to extend Resident 18's L elbow with minimal [loss of joint mobility]. OT 1 was able to extend Resident 18's R elbow with moderate [loss of joint mobility]. Resident 18 was observed with evidence of pain when OT 1 attempted to extend the R elbow for more than 90 degrees. OT 1 stated Resident 18's L elbow has better ROM than the R elbow. During an interview and concurrent review on 3/7/2024 at 12:16 PM with the Director of Rehab (DOR), Resident 18's OTEPT and JMS were reviewed. The DOR stated JMS indicated Resident 18 had a contracture on the right elbow with moderate loss of mobility with Resident 18 able to extend [the right elbow] up to 90 degrees. The DOR stated the discrepancy in the assessments and documentation could lead to an inaccurate treatment plan with the splint potentially not being consistently applied to the affected extremity. During a review of the facility's policies and procedures (P&P 1), titled Occupational Therapy, dated 2/19/2021, P&P 1 indicated the following: 1. OT's principal function is to provide services to those individuals whose abilities to cope with tasks of daily living were impaired by physical injury or illness, aging process, or psychosocial disability to achieve optimum functioning to prevent disability and maintain health. 2. OT furnishes evaluation information and assistance to the physician, as well as plans and carries out resident treatment in the form of exercise and purposeful activity. 3. OT assesses the resident's function and assists him/her in developing the necessary skills through which he/she can accomplish the goals. 4. Some of the OT treatment aims and objectives include reduction of physical disability and contractures management. B. During a review of Resident 18's OSR for 3/2024, the OSR indicated a physician's order, dated 12/4/2023, for RNA to apply the R elbow splint 2-4 hours daily 7 times per week as tolerated by Resident 18. During an interview and record review on 3/7/2024 at 10:15 AM with the DOR, Resident 18's OTEPT, OT Therapy Progress Reports (OT TPRs), OT Recert, Progress Report & Updated Therapy Plan (OT RPR&UTP), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 19 of 40 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 03/07/2024 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 0688 and OT Discharge Summary (OT DS) were reviewed. The DOR stated the following: Level of Harm - Minimal harm or potential for actual harm 1. Resident 18's OTPT 1, dated 10/20/2024, indicated Resident 18's LTG was to safely wear a L elbow splint for up to 2 hours with minimal s/s of redness, swelling, discomfort, or pain. Residents Affected - Few 2. Resident 18's OT TPRs, dated 10/26/23, 11/2/2023, 11/9/2023, 11/22/2023, 11/29/2023, 12/4/2023, indicated Resident 18 was able to tolerate the L elbow splint for 30 minutes or less. 3. Resident 18's OT RPR&UTP, dated 11/16/2023, indicated Resident 18 was able to tolerate the L elbow splint for less than 30 minutes. 4. Resident 18's OT DS, dated 12/4/2023, indicated Resident 18's LTG to safely wear a L elbow splint for up to 2 hours was met upon Resident 18's discharge from rehab therapy on 12/4/2023. However, OT DS indicated the discharge recommendations included the referral to the RNA splinting program for the application of the R elbow splint for 2-4 hours a day daily 7 times per week. During an interview and a concurrent review of Resident 18's records on 3/7/2024 at 10:54 AM with OT 1, Resident 18's OTEPT, dated 10/20/2023, was reviewed. OT 1 stated the OTEPT indicated the LTG for Resident 18 was to safely wear the L elbow splint for up to 2 hours to prevent the contractures and pain from getting worse, prevent any skin breakdown, and maintain Resident 18's hygiene. OT 1 stated Resident 18's RUE would have a tone (tension or amount of resistance in the relaxed muscle) such that Resident 18 would hold [her RUE] at that range. OT 1 stated RUE would not need splinting. During another interview and concurrent review on 3/7/2024 at 12:16 PM with the DOR, Resident 18's OT Treatment Encounter Note(s) (OT TENs) were reviewed. The DOR stated the discrepancy in assessments and documentation could lead to an inaccurate treatment plan with the splint potentially not being consistently applied to the affected extremity. The DOR stated this could lead to worsened contractures and skin breakdown. The DOR stated the following: 1. Resident 18's OT TENs indicated Resident 18's L elbow was treated on 10/20/23, 10/24/2023, 10/27/2023, and 11/30/2023. 2. Resident 18's OT TENs indicated Resident 18's R elbow splinting was assessed on 10/30/23, 10/31/2023, 11/1/2023, 11/3/2023, 11/6/2023, 11/8/2023, 11/10/2023, 11/13/2023, 11/14/2023, 11/15/2023, 11/17/2023, 11/20/2023, 11/21/2023, and 11/24/2023. 3. Resident 18's OT TEN, dated 11/28/2023, indicated Resident 18 tolerated the R elbow splint for 2.5 hours without skin irritation. 4. Resident 18's OT TEN, dated 11/30/2023, indicated Resident 18 tolerated the L elbow splint for 2 hours without skin irritation. 5. Resident 18's OT TEN, dated 12/1/2023, indicated Resident 18 tolerated the R elbow splint for 2 hours. During a review of the facility's policies and procedures (P&P 2), titled Provision of Rehab Services, dated 2/19/2021, P&P 2 indicated the following: 1. Organized skilled rehabilitation services must be provided within the facility by adequate, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 20 of 40 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 03/07/2024 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 0688 qualified staff under competent medical direction. Level of Harm - Minimal harm or potential for actual harm 2. The rehab services must relate directly and specifically to an active written treatment plan established by the physician after any needed consultation with the qualified therapist and must be reasonable and necessary to the treatment of the individual's illness or injury. Residents Affected - Few 3. The condition of the resident must be such that the services required can be safely and effectively performed only by a qualified therapist or under his/her supervision. 4. Prior level of function must be reported to support the therapist's functional goals for the resident. C. During a review of the Resident 18's PT Evaluation & Plan of Treatment (PTEPT), PT Therapy Progress Reports (PT TPRs), PT Treatment Encounter Note(s) (PT TENs), the PTEPT, PT TPRs, and PT TENs indicated the following: 1. Resident 18 was able to tolerate the extension splints to both knees (B knees) and left ankle (L ankle): a. 10/31/2023 - 1 hour b. 11/1/2023 - 1.5 hours c. 11/2/2023 - 1.5 hours d. 11/3/2023 - 1.5 hours e. 11/6/2023 - 1.5 hours f. 11/7/2023 - 1.5 hours g. 11/8/2023 - 1.5 hours h. 11/9/2023 - 2 hours i. 11/10/2023 - 2 hours j. 11/12/2023 - 3 hours k. 11/13/2023 - 2 hours l. 11/14/2023 - 2 hours m. 11/15/2023 - 3 hours During a review of Resident 18's OSR for 3/2024, the OSR indicated the physician's order, dated 12/4/2023, for the RNA to apply B knees splints and L ankle splint 2-4 hours daily 7 times per week as tolerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 21 of 40 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 03/07/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review on 3/7/2024 at 1:04 PM with Physical Therapist 1 (PT 1), Resident 18's PTEPT and PT Discharge Summary (PT DS) were reviewed. Resident 18's both knees would bend more and more if no splints were applied. PT 1 stated the final safe splinting time frame must be based on Resident 18's overall average performance at least 75% of the time. PT 1 stated the goal was to prevent worsened contractures, skin breakdown due to possible pressure sore (skin injury due to prolonged pressure on the skin) development related to the difficulty repositioning the resident. PT 1 stated Resident 18's PT DS indicated the following: 1. Resident 18's LTG was to tolerate splints to both knees and left ankle 3-4 hours daily without skin breakdown or redness. 2. Resident 18 was able to tolerate B knee splints without skin breakdown or redness up to 3.5 hours upon discharge from rehab therapy on 11/15/2023. 3. PT 1 stated it may be an unsafe practice to leave have RNA assess Resident 18's tolerance to B knee and L ankle splints past 3.5 hours. During an interview on 3/7/2024 at 3:14 PM, the Director of Nursing (DON) stated the rehab team must determine the safe splinting time frame of the resident (in general) prior to the implementation of the RNA orders. The DON stated the licensed nurse must consult with the rehab team if the splinting and/or ROM exercises were tolerated by the resident and would like to consider increasing the splinting time to ensure proper care and safety. During a review of the facility's policies and procedures (P&P 3), titled Physical Therapy, dated 2/19/2021, P&P 3 indicated the following: 1. The purpose of PT is to provide for the relief of pain, develop and/or restore function and to achieve and maintain maximum physical performance. 2. The goal of PT Department is to rehabilitate each resident to his/her maximal functional level. 3. PT responsibilities include assessment of residents and the therapeutic application of physical agents, exercise, and other procedures to maximize functional independence. 4. Services include the assessment and training of orthotic and prosthetic devices and assistive devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 22 of 40 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 03/07/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility's interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to accurately assess a resident's fall risk and reassess fall prevention interventions quarterly for one of one sampled resident (Resident 41) who was at high risk of falling, as indicated in the facility's policies and procedures (P&P). These failures had the potential to result in harm and Resident 41 to sustain injury and/or harm due to falls. (Cross reference F657) Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen). During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/23/23, the MDS indicated Resident 41 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 41 was dependent (helper does all the effort) on staff for bathing. The MDS indicated resident 41 required substantial to maximal assistance (helper does more than half the effort) from staff for toileting and dressing. The MDS indicated Resident 41 had one fall with major injury (bone fractures, joint dislocations, closed head injuries, with altered consciousness, subdural hematoma) at the facility. During a review of Resident 41's COC/Interact Assessment Form (SBAR, Situation, Background, Assessment, Recommendation, communication tool that helps provide essential patient information), dated 8/13/23, the SBAR indicated on 8/13/23 at around 6:00 a.m., Resident 41 stood up from Resident 41's bed without assistance from staff and fell to the floor. The SBAR indicated Resident complained of pain on Resident 41's right knee and right ankle. The SBAR indicated the nurse noted some swelling (did not indicate what body part was swollen). The SBAR indicated the facility received an order for Resident 41 to have a STAT (urgent or rushed) X-ray (a type of diagnostic imaging that creates pictures of the inside of your body) to see if Resident 41 had any fractures. During a review of Resident 41's Radiology Report, date of service 8/13/23, the Radiology Report indicated the X-ray of Resident 41's right ankle showed Resident 41 had an acute (sudden) ankle fracture. During a review of Resident 41's Physical Medicine & Rehabilitation Evaluation, dated 8/21/23, the Evaluation indicated Resident 41 had weakness and functional decline due to a recent fall at the facility where Resident 41 sustained a right ankle fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 23 of 40 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 03/07/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 3/7/24 at 9:04 a.m. with the MDS Nurse (MDSN), Resident 41's Fall Risk Assessment, dated 8/3/23 (10 days before Resident 41 fell), the Fall Risk Assessment inaccurately indicated Resident 41 was at low risk of falling. The MDSN stated the Fall Risk Assessment was inaccurate and should have indicated Resident 41 was at high risk of falling because Resident 41 had a diagnosis of dementia. The MDSN stated if Resident 41's Fall Risk Assessment had been scored accurately to indicate Resident 41 was at high fall risk of falling, then the IDT would have met to determine if Resident 41 was receiving the right interventions to minimize injuries for Resident 41. The MDSN stated residents (in general) received a fall risk assessment every quarter to determine fall risks of the residents. The MDSN stated if the resident was a high fall risk, the IDT discussed interventions to determine if the interventions still applied to the resident. During a concurrent interview and record review on 3/7/24 at 12:50 p.m. with the Director of Nursing (DON), Resident 41's care plan titled, Superstar Star ., initiated 1/21/22, revised 8/14/23, the care plan indicated Resident 41 was at risk of falling and/or injury secondary to, balance deficit, cognitive impairment, and poor safety awareness. The DON stated the care plan was created because Resident 41 was at high risk of falling. The DON stated if the quarterly fall risk assessment indicated Resident 41 was at high risk of falling, then the IDT (a group of healthcare professionals with various areas of expertise who worked together toward the goals of their clients) needed to review the care plan to determine if the interventions were still appropriate to reduce or prevent Resident 41 from falling. The DON stated Resident 41's medical record did not indicate the IDT was meeting quarterly to review Resident 41's fall risk interventions. The DON stated the IDT could have implemented new interventions if they met quarterly and reviewed the current interventions. During a review of the facility's P&P titled, Falling Star Program, undated, the P&P indicated, residents will be assessed for fall risk utilizing the fall risk assessment form and appropriate interventions will be provided. The P&P indicated a quarterly review needed to be done for residents who were at high risk of falling. The P&P indicated the facility needed to evaluate for appropriate useful interventions for fall reduction. During a review of the facility's P&P titled, Initial Fall Risk Assessment, undated, the P&P indicated if a resident was assessed to be a moderate to high risk of fall, a plan of care would be established immediately for implementation of interventions to attempt prevention of a fall. The P&P indicated, The plan of care will be reviewed by the IDT quarterly and as needed for update of the resident's current needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 24 of 40 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate treatment to restore continence, to the extent possible, by failing to implement a prompted toileting program (caregiver prompts the resident to use the toilet) for one of one sampled resident (Resident 15). This failure had the potential to result in incontinence and urinary tract infections (UTIs, an infection in any part of the urinary system [system of organs that makes urine]) to Resident 15. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/18/24, the MDS indicated Resident 15 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 15 required partial to moderate (helper does less than half the effort) assistance from staff for toileting, dressing, and bathing. The MDS indicated Resident 15 was incontinent of urine. The MDS indicated the facility did not implement a toileting program for Resident 15. During a concurrent interview and record review on 3/6/24 at 9:56 a.m. with the MDS Nurse (MDSN), Resident 15's MDS, dated 1/18/24 was reviewed. The MDS indicated the facility did not implement a trail of a toileting program (scheduled toileting, prompted voiding, or bladder training) for Resident 15. During an interview on 3/6/24 at 10:17 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 15 was incontinent of urine. CNA 1 stated Resident 15 sometimes went to the bathroom on her own and other times staff had to take Resident 15. During a concurrent interview and record review on 3/6/24 at 1:50 p.m. with the MDSN, Resident 15's Bowel and Bladder Program Screener, dated 1/19/24 was reviewed. The Bowel and Bladder Program Screener indicated 15 was a candidate for scheduled toileting. The MDSN stated the facility did not implement the prompted (scheduled) toileting program as indicated in the Bowel and Bladder Program Screener. The MDSN stated Resident 15 needed a prompted toileting program to prevent falls, UTIs, and to maintain Resident 15's dignity. During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder Assessment dated 1/2004, the P&P indicated, An assessment shall be completed using the RAP guideline, for each resident who is incontinent .to determine the resident's ability to participate in a bowel and/or bladder retraining program. The P&P indicated, If the resident is a candidate for a retraining program, include the following in the resident's health record: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 25 of 40 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 03/07/2024 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 0690 A physician's order for retraining program, Level of Harm - Minimal harm or potential for actual harm 2. An individualized resident re-training program specified on the care plan for the staff to follow, Residents Affected - Few 3. A realistic goal and estimated time period of the retraining program, 4. A flow sheet to reflect the individual plan being followed by the nurse assistant and the daily results of the program followed, 5. Weekly progress notes to be written by a licensed nurse to reflect the resident's progress and response to the program, 6. Re-evaluation of the program, as the resident needs change, 7. A DC note by a licensed nurse that includes the conclusion and maintenance program when the retraining is discontinued. 8. Care plan update to include a maintenance program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 26 of 40 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 03/07/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmacy consultant recommendations were followed for one of one sampled resident (Resident 9). The facility did not act upon recommendations to include ferritin/iron panel (a lab test that determines if the body has enough iron in the cells) in Resident 9's routine labs. This deficient practice had the potential to result in a physical decline to Resident 9. Findings: During a review of an admission Record (AR), the AR indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses that included anemia (a deficiency when the body does not have enough iron) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/9/24, indicated Resident 9 needed supervision for touching assistance with sit to lying (moves from lying flat to sitting in bed) and sit to standing (sting in a chair to standing). During a review of Resident 9's Order Summary Report (OSR), active orders as of 3/5/24, the OSR included a physician's order dated 4/7/21, the order indicated to have labs (blood tests are used to measure or examine cells, chemicals, proteins, or other substances in the blood) drawn for Ferritin and Iron panel every three months: December, March, June, and September for Resident 9. During a record review titled Consultant Pharmacist's Medication Regimen Review (MRR), for recommendations created between 1/1/24 and 1/24/24 and between 2/1/24 and 2/15/24. The reviews were completed by the facility's pharmacist consultant and indicated the, every three months routine lab orders for December 2023 did not include the ferritin/iron panel. The review indicated to verify lab schedule for the ferritin/iron panel. During an interview and concurrent record review on 3/6/24 at 1:23 p.m., the Director of Nursing (DON) stated Resident 9's pharmacy recommendations were not followed for ferritin/iron labs for December 2023 and January 2024. The DON stated it was important to monitor Resident 9's ferritin/iron levels to see if changes were needed or if corrections needed to be made. A review of the facility's undated policy and procedure (P&P) titled Consultant Pharmacist Reports-Medication Regime Review (Monthly Report), the P&P indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to mediation therapy. Recommendations are acted upon and documented by the facility staff and or the prescriber. If irregularities are found, the DON and/or designated licensed nurse will follow up with the prescriber within three working days of receipt of the MRR report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 27 of 40 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 03/07/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure the Lithium (medication used to treat mood disorders) level (blood drawn to check the Lithium level in the blood and determine if the level is within the therapeutic range [quantitative measurement of the relative safety of a drug], subtherapeutic [concentration of a drug lower than what is usually prescribed to treat a disease effectively], or indicating Lithium toxicity[an adverse drug reaction due to increased drug concentration in the blood]) for one of one sampled resident (Resident 6) was obtained as ordered by the physician. Residents Affected - Few This failure had the potential to cause lithium toxicity, worsened behavioral symptoms due to not enough drug in the blood, and a decline in Resident 6's physical and psychological well-being due to a delay in services. Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility initially admitted Resident 6 on 2/5/10 with multiple diagnoses including Parkinson's disease (progressive disorder affecting the nervous system and the body parts controlled by the nerves), convulsions (uncontrolled shaking of the body), and bipolar disorder (serious mental illness, causing unusual shifts in mood, energy, activity levels, and concentration). During a review of Resident 6's History and Physical (H&P), dated 2/20/24, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 2/16/24, the MDS indicated Resident 6 had severe impairment in cognition (ability to understand and process information). The MDS indicated Resident 6 required supervision or touching assistance (staff provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with mobility. The MDS indicated Resident 6 required partial/moderate assistance to supervision or touching assistance with some self-care activities. During a review of Resident 6's Order Summary Report (OSR), the OSR indicated the active physician's orders as of 3/6/24: 1. Order Date 12/4/14 - Lithium level every month. 2. Order Date 12/4/14 - Administer Lithium Carbonate 300 milligrams (mg. unit of measurement) 1 capsule by mouth at bedtime for bipolar disorder as manifested by constant hyperactivity (extreme restlessness or talking too much). During an interview and concurrent review of Resident 6's records on 3/6/24 at 2:31 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 6's AR, physician's orders, evaluations and progress notes, and laboratory results were reviewed. LVN 1 stated the Lithium level was not obtained in 9/2023 as ordered by the physician. LVN 1 stated it was important to obtain the Lithium level monthly to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 28 of 40 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 03/07/2024 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ensure it [the drug] was within the normal range and to inform the physician if the Lithium level was outside the normal range. During an interview on 3/7/24 at 3:14 p.m., the Director of Nursing (DON) stated Resident 6's Lithium level in the blood must be checked monthly to closely monitor the therapeutic level of the Lithium dose. The DON stated if the level was too low, the resident might have worsened behavioral symptoms. The DON stated if toxic levels were identified, the resident could have confusion, go into coma, or have other medical emergencies. During a review of the facility's policy and procedure (P&P), titled Laboratory Tests, undated, the P&P indicated laboratory requests must be completed as ordered or by month-end. The P&P indicated abnormal lab results must be communicated to the attending physician in a timely manner. The P&P indicated other laboratory values, such as normal labs, must be communicated to the attending physician as requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 29 of 40 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 03/07/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to date one opened bag of egg noodles and two open bags of chips in one of one food storage rooms (Food Storage room [ROOM NUMBER]), according to the facility's policy and procedure (P&P) titled, Labeling: Food. This failure had the potential to result in residents to experience food-borne illnesses (illnesses caused by contaminated food). Findings: During a concurrent observation and interview on 3/4/24 at 10 a.m. with the Certified Dietary Manager (CDM) in Food Storage room [ROOM NUMBER], three bags of opened foods were observed. There was one undated half full bag of egg noodles, one undated opened bag of tortilla chips, and one undated opened bag of potato chips all sitting on a shelf. The CDM stated the bags needed to be dated when opened to ensure kitchen staff used the bag before the food went bad. The CDM stated residents could get sick if served expired food. During a review of the facility's undated P&P titled, Labeling: Food, the P&P indicated, food that is cooked or open will be labeled with name of food item and date opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 30 of 40 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 03/07/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interviews and record review, the facility failed to ensure the medical records for one of one sampled resident (Resident 6) were complete and accurate. Residents Affected - Few This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided. Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility initially admitted Resident 6 on 2/5/10 with multiple diagnoses including Parkinson's disease (progressive disorder affecting the nervous system and the body parts controlled by the nerves), and convulsions (uncontrolled shaking of the body). During a review of Resident 6's History and Physical (H&P), dated 2/20/24, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 2/16/24, the MDS indicated Resident 6 had severe impairment in cognition (ability to understand and process information). The MDS indicated Resident 6 required supervision or touching assistance (staff provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with mobility. During a review of Resident 6's Order Summary Report (OSR), the OSR indicated the active physician's orders as of 3/6/24: 1. Order Date 12/4/14 - Administer Lithium Carbonate 300 milligrams (mg. unit of measurement) 1 capsule by mouth at bedtime for bipolar disorder (serious mental illness, causing unusual shifts in mood, energy, activity levels, and concentration) as manifested by constant hyperactivity (extreme restlessness or talking too much) During an interview and concurrent review of Resident 6's records on 3/6/24 at 2:31 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 6's AR, H&P, and physician's orders were reviewed. LVN 1 stated Lithium Carbonate was ordered by the physician for bipolar disorder, there was no documented evidence when Resident 6 was diagnosed with bipolar disorder. During a interview and concurrent review of Resident 6's records on 3/6/24 at 3:15 p.m., with MDS Nurse 1 (MDSN 1), Resident 6's AR and physician and psychiatric progress notes were reviewed. MDSN 1 stated Resident 6's AR on the chart [found in Resident 6's medical record] did not indicate a diagnosis of bipolar disorder, but Resident 6's Psychiatric Notes, dated 1/31/21, indicated a diagnosis of bipolar disorder. After record review, MDSN 1 provided an updated copy of Resident 6's AR indicating diagnosis of bipolar disorder. During an interview on 3/7/24 at 3:14 p.m., the Director of Nursing (DON) stated the AR consisted of important resident information including the residents' emergency contacts, dates of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 31 of 40 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 03/07/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission/readmission, basic profile, allergies, and diagnoses. The DON stated the residents' AR must be updated during readmission, after every diagnosis was added, or at least quarterly to ensure complete and accurate information was communicated between healthcare staff members. During a review of the facility's policy and procedure (P&P), titled Record Content: Documentation Principles, dated 1/2004, the P&P indicated the following: 1. All required records, either accurate reproduction thereof, must be maintained in such form as to be legible and readily available upon request by any person authorized by law to make such a request. 2. Resident's health record must be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident. 3. Entries must be complete, accurate, objective, specific, concise, legible, clear, and descriptive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 32 of 40 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 03/07/2024 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for two of two sampled residents (Residents 40 and 18) provided for following: Residents Affected - Few A. For Resident 40, the signed BAA failed to provide for the selection of a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties) and a neutral arbitrator (impartial or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute). B. For Resident 18, the signed BAA failed to provide for the selection of a convenient venue and a neutral arbitrator. These failures had a potential to result in a decline in the residents' physical and/or psychosocial condition due to the possible hardships related to arbitration proceedings. Findings: A. During a review of Resident 40's admission Record (AR), the AR indicated the facility initially admitted Resident 40 on 7/18/23 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), bipolar disorder (serious mental illness, causing unusual shifts in mood, energy, activity levels, and concentration), seizures (uncontrolled electrical activity in the brain), and generalized muscle weakness. The AR indicated Resident 40 had Responsible Party 1 (RP 1). During a review of Resident 40's History and Physical (H&P), dated 7/20/23, The H&P indicated Resident 40 did not have the capacity to make decisions due to dementia. During a review of Resident 40's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 7/23/24, the MDS indicated Resident 40 had severely impaired cognitive skills (ability to think, pay attention, process information, and remember) for daily decision making. The MDS indicated Resident 40 required extensive assistance with activities of daily living (ADL). During an interview and a concurrent review of Resident 40's BAA on 3/6/24 at 2:04 p.m., with Admissions Coordinator 1 (AC 1), Resident 40's BAA, dated 4/14/21, was signed by RP 1, AC 1 stated Resident 40's signed BAA did not provide a selection of a venue and a neutral arbitrator. B. During a review of Resident 18's AR, the AR indicated the facility originally admitted Resident 18 on 10/19/23 with multiple diagnoses including dementia, syncope (fainting) and collapse (fall down), anxiety disorder (persistent and excessive worry that interferes with daily activities), and generalized muscle weakness. The AR indicated Resident 18's primary decision maker was Responsible Party 2 (RP 2). During a review of Resident 18's H&P, dated 10/21/23, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 33 of 40 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 03/07/2024 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 0848 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 18's MDS, dated [DATE], MDS indicated Resident 18 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 18 required substantial to maximal assistance with most self-care activities and mobility. During an interview and a concurrent review on 3/6/24 at 2:04 p.m., with AC 1, Resident 18's BAA, dated 4/5/2017, signed by RP 2, was reviewed. AC 1 stated Resident 18's signed BAA did not provide for the selection of a venue and a neutral arbitrator. During an interview on 3/6/24 at 2:14 p.m., the Administrator stated the facility did not have any policies and procedures regarding BAA, since it was optional for the residents (in general). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 34 of 40 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 03/07/2024 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 0880 Provide and implement an infection prevention and control program. 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 maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled resident (Resident 41) when CNA 2 failed to wear personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while CNA 2 provided care to Resident 41 in accordance with the facility's policy and procedure (P&P). Residents Affected - Few This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria and viruses [organisms that cause disease] from one surface to another) and the spread of infection to Resident 41. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen). During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/23/23, the MDS indicated Resident 41 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 41 was dependent (helper does all the effort) on staff for bathing. The MDS indicated resident 41 required substantial to maximal assistance (helper does more than half the effort) from staff for toileting and dressing. The MDS indicated Resident 41 had an ostomy (allows bodily waste to pass through a surgically created stoma on the abdomen). During a concurrent observation and interview on 3/4/24 at 2:34 p.m. with Certified Nursing Assistant (CNA) 2, Resident 41 was lying in Resident 41's bed. CNA 2 was changing Resident 41's soiled brief (diaper) and CNA 2 was not wearing a gown (PPE) as indicated on the sign posted on Resident 41's room doorway. CNA 2 stated CNA 2 forgot to put on a gown before changing Resident 41's soiled brief. The sign at the doorway indicated staff were to wear a gown when changing incontinent (wet) briefs. During an interview on 3/5/24 at 12:13 p.m. with the Infection Preventionist (IP), The IP stated Resident 41 was on enhanced standard precautions (ESP, the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms [MDRO] to staff hands and clothing) because Resident 41 had a colostomy. The IP stated any resident who had a medical device (such as a colostomy) was placed on ESP to prevent staff from transmitting a MDRO to the resident (in general) and to protect the integrity of the resident. The IP stated staff needed to wear gowns and gloves whenever providing high contact tasks (such as changing wet briefs) for Resident 41. The IP stated Resident 41 could contract an infection if staff did not follow ESP protocol. During a review of Resident 41's care plan titled Other Contact Isolation: Enhanced Standard Precautions revised 4/13/23, the care plan's interventions indicated, Will observe standard barrier precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 35 of 40 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 03/07/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's P&P titled, Enhanced Standard Precaution, undated, the P&P indicated, Enhanced Standard Precaution involve gown and glove use during high contact resident activities for residents known to be infected or colonized with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The P&P indicated, Perform hand hygiene, wear gowns and gloves while performing the following tasks associated with residents who require Enhance [NAME] precaution: o Morning and evening care o Device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter, o Any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, transferring, respiratory care o Changing bed linens o Any care activity involving contact with environmental surfaces likely contaminated by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 36 of 40 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 03/07/2024 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **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 for 20 of 23 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,16, 17, 18, 19, 20, 21, 22, and 24). Nineteen resident rooms: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,16, 17, 18, 19, 20, 21, and 22 had two beds inside each room and one resident room: 24, had four beds inside the room. This deficient practice had the potential to result in the residents not to have enough room or move freely throughout their rooms and limit the space for facility staff to provide services and treatments for the residents residing in the rooms. Findings: During an observation of the initial tour of the facility on 3/4/24, between 11 a.m., to 12:30 p.m., 20 rooms (rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,16, 17, 18, 19, 20, 21, 22, and 24) were observed and did not meet the requirement of 80 square feet (sq./ft.) per residents in multiple resident rooms. Residents who resided in these rooms were able to ambulate freely and nursing staff had enough space to provide care to the residents. In these rooms, there was ample space for resident's beds, side tables, and dressers. During a review of the facility's room waiver request letter (RWRL) dated 3/4/24 indicated there was reasonable privacy, closet, and storage space provided in each resident room. The letter indicated there was sufficient room for staff to provide nursing care, enough room for resident equipment. The letter indicated all rooms had windows, no room was below ground level, and the health and safety of each resident would not be jeopardized by the waiver. The RWRL indicated the following total sq. ft. per room: Rm Beds Sq. Ft. 1 2 140 2 2 140 3 2 140 4 2 140 5 2 140 6 2 140 7 2 140 8 2 140 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 37 of 40 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 03/07/2024 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 0912 9 2 140 Level of Harm - Potential for minimal harm 10 2 140 11 2 140 Residents Affected - Some 12 2 140 16 2 140 17 2 140 18 2 140 19 2 140 20 2 140 21 2 140 22 2 140 24 4 308 The minimum square footage for a 2-bed room was 140 sq. ft. and for a 4-bed room [ROOM NUMBER] sq. ft. These rooms were below the minimum requirement. During an observation and concurrent interview with Maintenance Supervisor (MS) on 3/7/24 at 8:50 a.m., rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,16, 17, 18, 19, 20, 21, 22, and 24 were uncluttered and residents moved throughout their rooms freely. Residents presented no complaints regarding the size of their rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 38 of 40 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 03/07/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 the call light (a device used by a resident to signal the need for assistance) system was within reach for one of one sampled resident (Resident 41) as indicated in the facility's policy and procedure (P&P) titled, Call Lights. Residents Affected - Few This failure had the potential to result in unmet needs for Resident 41 or the potential to result in Resident 41 to experience harm if Resident 41 was unable to alert staff during an emergency. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen). During a review of Resident 41's care plan titled Resident has Self Care Deficits: revised 11/14/22, the care plan's interventions indicated to place the call light within reach of Resident 41. During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/23/23, the MDS indicated Resident 41 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 41 was dependent (helper does all the effort) on staff for bathing. The MDS indicated resident 41 required substantial to maximal assistance (helper does more than half the effort) from staff for toileting and dressing. The MDS indicated Resident 41 had one fall with major injury (bone fractures, joint dislocations, closed head injuries, with altered consciousness, subdural hematoma) at the facility. During an observation on 3/4/24 at 2:39 p.m., Resident 41 was asleep in Resident 41's bed. The call light cord was connected to the wall located near the foot of Resident 41's bed. The cord was stretched out and clipped on the blanket located next to Resident 41's left knee and was not within reach of Resident 41. During a concurrent observation and interview on 3/4/24 at 2:45 p.m. with Registered Nurse (RN) 1, Resident 41 was in Resident 41's bed. Resident 41's call light cord was stretched out and clipped on the blanket located next to Resident 41's left knee and out of reach for Resident 41. RN 1 moved the call light cord close to Resident 41's left hand. RN 1 stated Resident 41 was not able to reach the cord because it was clipped near Resident 41's left knee. During a concurrent observation and interview on 3/6/24 at 2:23 p.m. with the Director of Nursing (DON), Resident 41's call light cord was clipped to Resident 41's blanket located next to Resident 41's left knee and was out of reach for Resident 41. The DON stated the DON would instruct maintenance to make the cord longer so Resident 41 could reach the call light cord. The DON stated Resident 41 should have a call light in case Resident 41 needed assistance. The DON stated the call light was the only way residents (in general) could alert staff when they needed help. During a review of the facility's P&P titled, Call Lights, undated, the P&P indicated the purpose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 39 of 40 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 03/07/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm of the policy was to ensure residents received prompt assistance. The P&P indicated nursing and care duties included, ensuring that the call light is within the resident's reach when in his/her room or when on the toilet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555106 If continuation sheet Page 40 of 40