Health inspection·November 5, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some urinary system), retention of urine (difficulty urinating and completely emptying the bladder), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 181's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/16/21, indicated Resident 181 had short-term memory problem and her daily decision making was moderately impaired. The MDS indicated Resident 181 required supervision with transfers, walking in room, and locomotion off unit. The MDS indicated Resident 181 required limited assistance with dressing, toilet use, and personal hygiene. During an observation on 11/1/21 at 9:49 am, Resident 181 was walking in the hallway with foley catheter drainage bag (bag that collects urine) was not covered. During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 11/1/21 at 10:15 am, she stated was responsible for Resident 181's care. LVN 2 went to inside Resident 181's room and confirmed Resident 181's foley catheter drainage bag was uncovered. LVN 2 stated the foley catheter drainage bag should be covered. During a concurrent interview and observation on 11/1/21 at 12:47 pm, Resident 181's Foley bag was not covered. When asked how it makes her feel that the Foley bag is uncovered, Resident 181 stated, I don't like it. During an observation on 11/3/21 at 8:13 am, Resident 181 was walking in the hallway with uncovered foley catheter drainage bag . A review Resident 181's Care Plan for Foley Catheter dated 11/2/21 indicated staff to treat resident with respect and dignity. A review of the facility's undated Policy and Procedure, titled Privacy: Maintenance of Dignity, indicated the facility will protect the dignity of residents that includes the provision of privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 2 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 accommodate resident needs for one of 38 sampled residents by failing to ; Residents Affected - Few 1. Provide telephone access for Resident 44 in the [NAME] Side Men's Wing. 2. Ensure the light switch cord was within easy reach of Resident 44. These deficient practices had the potential for Resident 44 to not be able to achieve independent functioning and well-being in accordance with the resident's own needs and preferences. Findings: 1. A review of Resident 44's admission Record indicated the resident was admitted on [DATE], with diagnoses including muscle wasting and atrophy (occurs when muscles waste away as a result of lack of physical activity) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 44's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/17/2021, indicated the resident had no cognitive ( ability to understand) impairment. The MDS indicated Resident 44 required supervision with bed mobility, transfers, walking and required limited assistance (staff provided guided maneuvering of limbs or other non-weight-bearing assistance) with dressing, toilet use, and personal hygiene. The MDS indicated the resident used a wheelchair for mobility and was not steady when moving on and off the toilet. During an observation on 11/2/21 at 11:44 am, Resident 44 was lying in bed. There was an overhead light on top of the bed, located on the head part of the bed. The overhead light had a cord that was 1.5 inches in length. Resident 44 stated he did not use the light because he could not reach the cord and it would be helpful to be able to use the light at night so he can see better. A review of the facility's undated Policy and Procedure titled Accommodation of Needs indicated there should be adaptations of the resident's bedroom and furniture that is reasonable for resident care needs. 2. During a concurrent observation and interview on 11/2/2021 at 11:46 am, Resident 44 stated he cannot use a phone in the facility. He states, the CNAs ( general) would tell him there's a specific time to use a phone. Resident 44 stated he asked a facility staff five days ago to use a phone and he was told he could not use the phone at that time. During an observation on 11/2/2021 at 12:21 pm, there were seven resident rooms and one staff room in the [NAME] Side Men's Wing. There was no phone inside the staff room and no phone throughout the [NAME] Side Men's Wing. A review of the facility's phone location indicated there was one public phone located in the East Wing (locked unit) and for the 3 buildings in the [NAME] Wing, the phone for the resident to use was in the nurse's station of the Women's Wing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 3 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation of the Women's Wing on 11/5/2021 at 8:44 am, there were two telephones inside the nurse's station. One of the telephones did not have a cord long enough to reach the counter for residents to use. Another telephone had a cord that is not long enough to reach the counter where residents stand. In a concurrent interview, Licensed Vocational Nurse 7 (LVN 7) stated the [NAME] Wing did not have a payphone and there was no cordless phone that the residents in the [NAME] Wing can use. LVN 7 stated residents in the [NAME] Wing had to go to the nurse's station which was located in another building in order for residents to access the telephone. LVN 7 stated when residents had to make a phone call he could leave the nurse's station, but he could not leave the nurse's station when he was preparing and/or passing medications. A review of the facility's undated Policy and Procedure titled Accommodation of Needs indicated residents will receive services in the facility with reasonable accommodation of individual needs and preferences. A review of the facility's undated Policy and Procedure titled Resident Rights, Purpose and Policies indicated the facility shall provide accessible telephones to all residents for making or receiving calls. The telephones are located in areas which permit access by wheelchairs, provide seating for the person using the telephone, and provide privacy for the telephone conversation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 4 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 licensed nurse failed to report a resident's fall to the physician for one of six sampled residents ( Resident 10). This deficient practice had the potential for Resident 10 not to receive needed care and services in a timely manner after a fall and to prevent further falls. Findings: A review of Resident 10's admission Record indicated the resident was admitted on [DATE], with diagnoses including bipolar disorder (a mental health illness that causes extreme mood swings) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/10/2021, indicated the resident had no cognitive ( ability to understand) impairment, was able to express ideas and wants and able to understand others. The MDS indicated the resident required supervision with bed mobility, transfers, walking and eating and required limited assistance (staff provide guided maneuvering of limbs of other non-weight-bearing assistance) with dressing and toilet use. During an observation on 11/1/2021 at 1:26 pm inside Resident 10's room, the resident was lying on the floor with his left arm under him, the wheelchair was beside him and Licensed Vocational Nurse 2 (LVN 2) was inside the room. There was a left knee open wound on Resident 10. Certified Nursing Assistant 1 (CNA 1) came and assisted LVN 2 move the resident back to the wheelchair. During an interview on 11/1/2021 at 1:32 am, Resident 10 stated he came out of the restroom and fell out of the chair. Resident 10 stated he hit his left shoulder and his head on the floor. A review of Resident 10's Nurse's Notes did not indicate the resident's fall was documented and there was no documentation the physician was notified of the resident's fall incident. During an interview with LVN 2 on 11/3/2021 at 12:41 pm, she stated she called the doctor's office to notify the physician regarding Resident 10's fall but she could not remember the person she gave the report. During an interview with the Director of Nursing (DON) on 11/3/2021 at 1:16 pm, he stated if there was a fall incident, the charge nurse needed to notify the attending physician so the physician can be made aware and provide MD orders after the fall. During a telephone interview on 11/10/21 at 11:07, Resident 10's attending physician stated he was not notified of Resident 10's fall incident on 11/1/2021. A review of Resident 10's plan of care for Fall revised on 11/26/2020, indicated to notify the physician as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 5 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 A review of the facility's List of Resident Rights dated December 1991, indicated the facility must immediately consult with the resident's physician when there is an accident involving the resident and has the potential for requiring physical intervention. A review of the facility's Policy and Procedure titled Documentation in the Medical Record indicated Documentation of Physician Notification shall be completed as follows; a. Date of notification b. Time of notification c. Name of person receiving notification d. Response of person receiving notification FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 6 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to : Residents Affected - Some 1. Ensure facility staff accurately complete the Medication Administration Record (MAR) for October 2021 for six of 38 sampled residents (Resident 6, 9, 43, 66, 67, and 68). 2. Obtain physician's signature for Informed Consent for medication for three of 38 sampled residents (Residents 43, 66 and 81). These deficient practices had the potential for staff not to provide needed care and services to the residents in accordance with professional standard of care. Cross Reference: F758 Findings: 1 a. A review of Resident 67's admission Record indicated the resident was admitted to facility on 8/9/2021 and readmitted on [DATE] with diagnoses including type II diabetes mellitus (high blood sugar), and epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time). A review of Resident 67's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/6/2021, indicated the resident's cognitive (ability to understand) skills for daily decision making was intact. The MDS indicated, Resident 67 required supervision to extensive assistance from staff for his activities of daily living. The MDS indicated Resident 67 was readmitted on [DATE] and received insulin injection medication during the last 7 days or since re-admission/entry. A review of Resident 67's Physician Orders for the month of November 2021, indicated the following: - Monitor symptoms and signs of COVID -19 - document temperature, respiratory rate, oxygen saturation every shift; the order was dated 10/12/2021. - Monitor symptoms and signs of COVID 19 - (1) cough (2) shortness of breath (3) fatigue (4) chills (5) muscle or body ache (6) sore throat (7) new loss of taste or smell (8) headache (9) congestion or runny nose (10) diarrhea (11) nausea or vomiting. Document: N for No, Y for Yes, (if Yes, indicate in the nurse's note and call medical doctor) every shift. The order was dated 10/12/2021. A review of Resident 67's Medication Administration Record for 10/1/2021 to 10/31/2021 with MDS assistant (MDSA) indicated on 10/12/2021, the morning shift staff did not document the monitoring of symptoms and signs of COVID-19 and document every shift, as ordered. During a concurrent interview on 11/3/2021 at 1:40 PM with the MDSA, confirmed the finding and stated staff did not chart and did not monitor symptoms and signs of COVID 19 as ordered. 1 b.A review of Resident 68's admission Record indicated the resident was admitted to facility on 10/1/2021 with diagnoses including type II diabetes mellitus (high blood sugar), and arteriosclerotic heart disease (thickening and hardening of the walls of the coronary arteries). A review of Resident 68's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 7 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for daily decision making was intact. The MDS indicated Resident 68 required supervision to extensive assistance from staff for his activities of daily living. The MDS indicated Resident 68 received the following medications: insulin injection, antipsychotic, and antidepressant medications during the last 7 days or since admission/entry. A review of Resident 68's History and Physical dated 10/5/2021 indicated the resident was able to make decisions for activities of daily living. A review Resident 68's recapitulated Physician Orders for the month of November 2021 indicated the following: - Monitor behavior for major depressive disorder manifested by (m/b) self expression of sadness, and tally wish yashmaks 0=absence 1=presence every shift for the use of Duloxetine. - Monitor behavior for major depressive disorder m/b panicky feeling causing stress, and tally with hashmarks 0=absence 1=presence every shift for the use of Trazodone. - Monitor behavior for schizophrenia m/b extreme negative thoughts interfering with daily living and self care, and tally with hashmarks 0=absence 1= presence every shift for the use of Seroquel. - Monitor anticoagulation medication for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifices, abnormal labs. Document: N, if monitored and none observed. Document: Y if monitored and any of the above observed. - Notify medical doctor (MD) and document in nurses' progress notes every shift for aspirin. - Monitor adverse side effect (ASE) for cognitive impairment and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for Parkinson syndrome (unchanging facial expression, drooling, tremors, rigidity) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for akathisia (motor restlessness, anxiety) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for tardive dyskinesia (involuntary movements of tongue, jaw, face and mouth) and tally with hashmarks 0=absence 1=presence every shift. - Monitor for potential side effects of anti depressant (Duloxetine) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of anti depressant (Trazadone) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 8 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Monitor for potential side effects of antipsychotic (Seroquel) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, shuffling gait, drooling, weight gain, photosensitivity. - Monitor for symptoms and signs of Covid-19 and document, temperature, respiratory rate, oxygen saturation every shift. Monitor symptoms and signs of Covid -19. 1-cough, 2-shortness of breath, 3-fatigue, 4-chills, 5-muscle or body ache, 6-sore throat, 7- new loss of taste or smell, 8-headache, 9-congestion or runny nose, 10-diarrhea, 11-nausea or vomiting. Document: N=no, Y=yes, (if Yes, indicate in the nurse's note and call medical doctor) every shift. - Pain assessment (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10=very severe pain) every shift. - Aspirin 325 milligram (mg- unit of measurement) by mouth one time a day for pain. - Duloxetine capsule delayed release sprinkle 30 mg 1 capsule by mouth one time a day related to major depressive disorder, single episode, m/b self expression of sadness. - Lantus Solostar Solution Pen-injector (insulin Glargine) 100 unit/milliliter (U/ml) inject 20 units subcutaneously (SQ) every morning and at bedtime related to type II diabetes mellitus without complications, ordered 10/1/21, - Insulin Lispro solution inject per sliding scale, ordered 10/1/21. - Seroquel tablet 300 mg one tablet by mouth at bedtime related to schizophrenia m/b extreme negative thoughts interfering with daily living and self care. - Seroquel tablet 50 mg one tablet by mouth two times a day related to schizophrenia m/b extreme negative thoughts interfering with daily living and self care. - Trazodone 50 mg tablet one tablet by mouth at bedtime related to major depressive disorder, single episode, unspecified m/b panicky feeling causing stress. A review of Resident 68's Medication Administration Record for 10/1/2021 to 10/31/2021 with MDS assistant (MDSA) indicated on 10/1/2021 and 10/2/2021 the night shift staff did not document monitoring behavior for major depressive disorder, schizophrenia, cognitive impairment, parkinson syndrome, akathisia, tardive dyskinasia, side effect of antidepressant Duloxetine and Trazadone, and antipsychotic Seroquel, anticoagulation, signs and symptoms of Covid 19, and pain assessment. During a concurrent interview with MDSA on 11/3/2021 at 12:50 p.m., she confirmed the finding and stated staff did not document in the MAR as ordered. A review of the facility's undated Policy and Procedure titled Documentation in Medical Record indicated all pertinent information concerning the resident shall be documented in the resident's medical record. A review of the job description for Licensed Vocational Nurse (LVN) dated 8/23/11 included to monitor side effects of medications as indicated, provide pain medication interventions as ordered, including evaluation of interventions and provide resident teaching regarding medication as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 9 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the Job Description for Registered Nurse (RN) dated on 8/23/11, included establish and implement patient plans of care and document care provided appropriately, monitor condition changes and properly document and follow-up as necessary. 1c. A review of Resident 6's admission Record indicated the resident was admitted to facility on 7/22/2020, and readmitted on [DATE], with diagnoses including paranoid schizophrenia (a type of schizophrenia (mental disorder) associated with feelings of being persecuted or plotted against) A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 8/8/2021 indicated the resident's cognitive ( ability to understand) skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 6 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 6's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 6 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - 10/2/2021 (night shift) for monitoring behavior related to schizophrenia, cognitive impairment, adverse side effects for parkinsonism, akathisia, tradive dyskinesia, potential side effects for the use of haloperidol/zyprexa, oxygen saturation monitoring, monitoring s/sx of Covid 19, pain assessment, monitoring BP every shift(night shift) and monitoring for orthostatic hypotension on evening shift every Friday - 10/3/2021 for administration of Protonix 40 mg for GERD at 6:00 am. During an interview on 11/03/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 6 and medication administration were done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day, as ordered. DON stated the MAR should be completed . 1d. A review of Resident 9's admission Record indicated the resident was admitted to facility on 8/1/19 and readmitted on [DATE], with diagnoses including schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 9's Minimum Data Set, dated [DATE], indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 9 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 9's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 9 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - On 10/1/2021 and 10/2/2021 (night shift) for pain assessment, monitoring s/sx of Covid 19, monitoring for side effects of zyprexa, adverse side effects for tardive dyskinesia, parkinsonism, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 10 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 akathisia, monitoring behavior for schizophrenia and monitoring for cognitive impairment. Level of Harm - Minimal harm or potential for actual harm - On 103/2021 for administration of famotidine 20 mg for GERD at 6:00 am. Residents Affected - Some During an interview on 11/03/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 9 and medication administration was done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day, as ordered. DON stated the MAR should be completed . 1e. A review of Resident 43's admission Record indicated the resident was admitted to facility on 9/9/2021 with diagnoses including type 2 diabetes mellitus (high blood sugar), muscle wasting and atrophy (a loss of muscle mass due to the muscle weakening and shrinking) and psychotic disorder (a condition that causes loss of reality). A review of Resident 43's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision to extensive assistance from staff for activities of daily living. The MDS indicated Resident 43 received antipsychotic and hypnotic medications during the last 7 days or since admission/entry. A review of Resident 43's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 43 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - On 10/1/2021 and 10/2/2021 (night shift) for pain assessment, side effects for the use of depakote/zyprexa, monitor for adverse side effects akathisia/tardive dyskinesia, cognitive impairment, parkinsonism,psychosis, psychotic delusion. - On 10/2/2021 and 10/3/2021 for monitoring s/sx of Covid 19. - On 10/3/2021 ( morning shift) for monitoring for side effects for the use of depakote/zyprexa, monitoring for cognitive impairment and Parkinson, monitor behavior for psychosis. - On 10/3/2021 for administering Humulin 70/30 insulin 32 units subcutaneous injection related to diabetes. - On 10/4/2021, 10/5/2021, 10/6/2021 for administering Humalog injection per sliding scale for 11:30 am. During an interview on 11/03/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 43 and medication administration was done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day, as ordered. DON stated the MAR should be completed . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 11 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1f. A review of Resident 66's admission Record indicated the resident was admitted to facility on 3/27/2014 and readmitted on [DATE], with diagnoses including paranoid schizophrenia. A review of Resident 66's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 66 received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 66's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 66 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - On 10/29/2021 (day shift) for pain assessment, monitoring for side effects of the use of risperdal/depakote/seroquel, monitoring for tardive dyskinesia and monitoring for s/sx of Covid 19. During an interview on 11/3/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 66 and medication administration was done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day. 2a. A review of Resident 43's admission Record indicated the resident was admitted to facility on 9/9/2021 with diagnoses including type 2 diabetes mellitus (high blood sugar), muscle wasting and atrophy (a loss of muscle mass due to the muscle weakening and shrinking) and psychotic disorder (a condition that causes loss of reality). A review of Resident 43's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision to extensive assistance from staff for activities of daily living. The MDS indicated Resident 43 received antipsychotic and hypnotic medications during the last 7 days or since admission/entry. A review of Resident 43's Informed Consent for Zyprexa medication, dated 10/6/2021 indicated the ordering physician's signature was missing. The consent indicated the resident consented for medication and the facility's representative signature and date were documented. During an interview on 11/4/2021 at 3:55 p.m., DON stated the ordering physician had 14 days to sign the Informed Consent and that nurses should not continue giving the medication if there's no physician's signature. 2b. A review of Resident 66's admission Record indicated the resident was admitted to facility on 3/27/2014, and readmitted on [DATE], with diagnoses including paranoid schizophrenia. A review of Resident 66's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 66 received antipsychotic medication during the last 7 days or since admission/entry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 12 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 66's Informed Consent for Seroquel, Risperdal and Depakote medications, all dated 2/25/2020 indicated the ordering physician's signature was missing. The Informed Consents were obtained through the phone and consent was given by the resident's mother. The consent indicated tthe facility's representative signature and date were documented. During an interview on 11/4/2021 at 3:55 p.m., DON stated the ordering physician had 14 days to sign the Informed Consent and that nurses should not continue giving the medication if there's no physician's signature. 2c. A review of Resident 81's admission Record indicated the resident was admitted to facility on 3/27/2020, and readmitted on [DATE], with diagnoses including dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and schizophrenia . A review of Resident 81's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was severely impaired and required limited assistance to total dependence from staff for activities of daily living. The MDS indicated Resident 81 did not receive any medication during the last 7 days. A review of Resident 81's Informed Consent for Olanzapine medication, dated 12/12/2021 indicated the ordering physician's signature was missing. The Informed Consent was obtained through the phone and consent was given by the daughter. The consent indicated the facility's representative signature and date were documented. During an interview on 11/4/2021 at 3:55 p.m., DON stated the ordering physician had 14 days to sign the Informed Consent and that nurses should not continue giving the medication if there's no physician's signature. A review of the facility's undated Policy and Procedure, titled Psychotropic Medications indicated all medications used within the facility are to be ordered by a physician and informed consent will be obtained from physician prior to administering psychotherapeutic drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 13 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to thoroughly investigate Resident 10's fall episode on 11/1/2021. Residents Affected - Few This deficient practice had the potential to put Resident 10 at risk for repeated falls, injury, and harm. Findings: A review of the admission Record indicated Resident 10 was admitted on [DATE], with diagnoses that included bipolar disorder (a mental health illness that causes extreme mood swings that include emotional highs [mania] and lows [depression], and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 8/10/21, indicated Resident 10 had no cognitive (mental action or process of acquiring knowledge and understanding) impairment, was able to express ideas and wants and was able to understand others. During a concurrent observation with Licensed Vocational Nurse 2 (LVN 2) on 11/1/2021 at 1:26 pm inside Resident 10's room, Resident 10 was lying on the floor sideways. The wheelchair was observed beside Resident 10. Resident 10 was observed to have sustained a left knee open wound. Certified Nursing Assistant 1 (CNA 1) came and assisted LVN 2 move Resident 10 back into the wheelchair. During a concurrent observation and interview on 11/1/2021 at 1:32 am, Resident 10 stated he came from the restroom and then in action he reached for the floor and stated, I fell out of the chair. Resident 10 stated he hit his left arm and his head on the floor when he fell. During a concurrent record review of Resident 10's clinical record and interview with LVN 2 on 11/3/2021 at 12:41 pm, LVN 2 confirmed that there was no documentation of Resident 10's fall incident dated 11/1/2021 on the change of condition report, nurses's notes, communication report to other staff and anywhere in the clinical record. During an interview on 11/3/2021 at 1:16 pm, the Director of Nursing (DON) stated if there was a fall incident, the Charge Nurse (CN) needed to inform the Registered Nurse Supervisor (RN Supervisor) and the DON. DON stated the RN Supervisor would conduct an assessment on the resident who had a fall. DON stated he needed to be informed of the Resident's fall so he could ensure processes would be followed after the fall. The DON stated the CN would need to fill up a change of condition (COC) report in order to , track fall episodes to prevent future falls. DON also stated the CN would need to notify the attending physician so he can be made aware and could provide MD orders after the fall. During an interview on 11/3/2021 at 1:28 pm, the RN Supervisor stated there was no fall reported for 11/2021. The RN Supervisor stated if a resident fall occurred, the CN assigned to the resident would need to document, complete a COC report and observe the resident for 72 hours. The RN Supervisor stated the CN would need to assess the resident for any injury and perform a neurocheck to ensure there was no head injury. RN Supervisor stated the CN should notify the RN supervisor or the DON and ask for advise if she did not know the process to follow after a fall incident. RN Supervisor stated the CN would also need to report Resident's fall incident to the doctor. The RN Supervisor stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 14 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN 2 who was assigned to Resident 10 did not inform him regarding Resident 10's fall incident on 11/1/2021. RN Supervisor stated Resident 10 should have been assessed for injuries from the fall. During an interview on 11/05/21 at 11:25 am, CNA 1 stated sometimes Resident 10 was unstable to walk and he would fall. CNA 1 stated, Sometimes when I walk with him, he would just fall to the floor. I was not the assigned CNA that day he fell but I saw him on the floor so I assisted the nurse to get him up from the floor. A review of the undated facility's Policy and Procedure (P&P) titled, Incidents/Accidents, indicated incidents/accidents will be reported to the charge nurse and documented on the accident/incident repost as soon as they occur. The charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report. The P&P indicated nursing assessment and documentation of incident on: 2. Nurse's Notes to include: a. Complete body check b. Documentation of resident's activities prior to incident c. M.D notified d. M.D orders carried out e. Family notified f. Vital signs taken with neurocheck on any head injury X72 hours 3. Care plan entry 4. Investigation incident/fall 5. Documentation of conclusion and steps taken to prevent recurrence completed within 5 days. 6. In-service as related to incident 7. Post Fall Assessment completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 15 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of eight sampled residents (Resident 17) by failing to remove an unoccupied metal bed frame in Resident 17's room. This deficient practice had the potential to put Resident 17 at risk for falls, injury, and harm. Findings: A review of the admission Record indicated Resident 17 was readmitted to the facility on [DATE] with diagnoses which included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and hypertension (increased blood pressure). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 8/15/2021 indicated Resident 17 had clear speech, had the ability to understand others and make self understood. Resident 17 required supervision (oversight, encouragement or cueing) with set up help only for transfer, walking in room, walking in corridor and toilet use. During an observation in Resident 17's room and concurrent interview on 11/1/2021 at 9:55 am, Resident 17 was sitting on a chair, which was in between the foot board of his bed and the head board of an unoccupied metal bed frame (without a mattress). Resident 17's bed side table was infront of him with a cup of water on top of it. The head portion of the unoccupied metal bed frame was elevated and was higher than the head board, with the corners pointing outward. The space where Resident 17 sat was only enough for one chair. Resident 17 stated this was a three occupancy resident room. Resident 17 stated the unoccupied metal bed frame was in his room for awhile now. Resident 17 stated he did not know why this was stored inside the room because it was taking away a lot of space. Resident 17 stood up, pushed away his bed side table to get out of chair and walked around the room with unsteady steps while trying to hold on to support surface. During an interview on 11/1/2021 at 10:05 am, Maintenance Supervisor (MS) stated Resident 17's room should only have three beds since it was a three occupancy resident room. MS stated he did not know why the 4th bed frame was in this room. MS stated the facility should not put an extra bed in Resident 17's room. MS stated it was a dangerous environment for Resident 17 especiallyit was a metal bed frame with the corners pointing out. MS stated this was an accident hazard. MS stated if Resident 17 falls, he could injure himself by accidentally hit his head on corner of the metal bed frame. MS stated an extra bed in room took away living space from residents and limited their movement in the room. MS stated it was important to keep residents free from possible injury. A review of Resident 17's care plan, initiated 1/23/2019 indicated Resident 17 was at risk for falls/injury because of arthritis (inflammation of joints), behavioral problems, dementia (an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities). The care plan interventions included was for the staff to provide a safe and cluster-free environment. A review of the facility's undated policy and procedure titled, Accident Prevention Policy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 16 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 Procedure, indicated this facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accident and/or falls, provision of adequate care plans with procedures to prevent accidents, provision of adequate supervision and provision of assistive devices as indicated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 17 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 observation, interview, and record review, the facility failed to ensure one of one sampled residents (Residents 108) with a urinary indwelling catheter (a tube inside that removes urine from the bladder to a collection bag) receive appropriate care by failing to keep the urinary indwelling catheter secured and anchored and keep the foley drainage bag below the bladder in accordance to facility policy, Resident 181's care plan and physician order. This deficient practice resulted to Resident 181's urinary catheter dislodgment and had the potential to result in catheter related complications such as urethral tear (injury to the urethra [tube-like organ that carries urine from the bladder out of the body] or to result in a delay of necessary care, treatment, and possible infection. Findings: A review of the admission Record indicated Resident 181 was readmitted to the facility on [DATE] with diagnoses of, but not limited to, urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder), retention of urine (difficulty urinating and completely emptying the bladder), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). A review of the Minimum Data Set (MDS, a standardized assessment and screening tool), dated 9/16/2021, indicated Resident 181 had a short-term memory problem and impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. MDS indicated Resident 181 required supervision with transfers, walking in room, and locomotion off unit. MDS also indicated Resident 181 required limited assistance with dressing, toilet use, and personal hygiene. A review of Resident 181's Order Summary Report, dated 11/1/2021 indicated to secure Foley catheter tubing with anchor to minimize dislodging of catheter. During an observation on 11/1/2021 at 9:49 am, Resident 181 got out of bed on her own and walked in the hallway. Resident 181 pushed a pole with the enteral feeding (nutrition delivered directly to the stomach) pump attached to the pole. The Foley catheter tubing was wrapped around the pole where the enteral feeding was attached. Foley catheter tubing was not secured to Resident 181's leg. During a concurrent observation in Resident 181's room and interview on 11/1/21 at 10:15 am, Licensed Vocational Nurse 2 (LVN 2) stated Resident 181's foley catheter tubing was not secured to resident's leg and the plastic clip on the foley catheter was not clipped to anything. LVN 2 stated the foley catheter should have been secured to avoid being pulled out. During a concurrent observation in Resident 181's room with Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) on 11/1/21 at 1:39 pm, Resident 181 was observed trying to pull the foley catheter out. Resident 181's foley catheter was observed not secured. During an interview on 11/2/21 at 10:50 am, MDSC stated Resident 181 must go to the hospital to have the Foley catheter re-inserted because she pulled the Foley catheter out. MDSC stated Resident 181 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 18 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 needed catheter re-inserted due to diagnosis of urinary retention. Level of Harm - Minimal harm or potential for actual harm A review of Resident 181's Change of Condition (COC)/Interact Assessment Form (SBAR), dated 11/2/2021 indicated Resident 181 pulled out her Foley catheter, was bleeding, and complained of pain. Documentation also indicated Resident 181 would be transferred to the hospital for re-insertion of the Foley catheter Residents Affected - Few During an observation on 11/3/21 at 6:53 am, Resident 181 was in her bed with the foley drainage bag hanging off the enteral feeding machine. Resident 181's foley drainage bag was above her waist level. During a concurrent observation and interview with LVN 2 on 11/3/21 at 8:37 am, Resident 181 was observed to have a leg device on her right leg. LVN 2 stated the device was to keep the foley catheter in place and prevent it from being pulled out. Resident 181's foley catheter tubing was observed not secured in the device. During an interview on 11/3/21 at 1:15 pm, Restorative Nurse Assistant (RNA) stated the foley drainage bag should be lower than her bladder, if not the urine could backflow and cause an infection. RNA stated the Foley catheter tubing should be attached to Resident 181's leg to prevent it from being pulled out. A review of Resident 181's Care Plan for Foley Catheter, initiated on 10/29/2021 and revised on 11/2/2021 indicated staff interventions were for the staff maintain proper alignment of the foley catheter to promote proper drainage. A review of Resident 181's Care Plan titled, Change of Condition, dated 11/2/2021, indicated staff interventions were for the nurse to provide standard nursing care, reassurance, alleviate pain or discomfort as needed and for a resident to be assessed by licensed nurse. A review of the facility's undated policy titled, Foley Catheter Maintenance, indicated staff interventions were to never elevate the drainage bag to or above the level of the bladder with the objective to prevent backflow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 19 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0692 Provide enough food/fluids to maintain a resident's health. 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 staff failed to follow physician's order for G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding in accordance with professional standards of practice for one of five sampled residents (Resident 27.) Residents Affected - Few This deficient practice had the potential for Resident 27 not to receive needed nutrition which could lead to malnutrition. Findings: A review of Resident 27's admission record indicated the resident was readmitted to the facility on [DATE] with diagnosis including dysphagia (difficulty swallowing), and Gastrostomy (the creation of an artificial external opening into the stomach for nutritional support or medication administration ). A review of Resident 27's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/1/2021 indicated the resident had unclear speech, usually understood others and made self understood. Resident 27 required total dependence (full staff performance every time) with one person physical assistance for transfer, eating and personal hygiene. A review of Resident 27's Order Summary Report for active orders as of 11/1/2021 indicated an order of enteral feeding, once a day of Jevita 1.5 CAL ( formula that provides complete, balanced nutrition for tube feeding) at 55 milliliters (ml- unit of measurement) per (each) hour for 8 hours via pump to provide 440 ml/660 kcal per day, to start from 6 PM to 2 AM. During an observation on 11/1/2021 at 12:30 pm, Resident 27 was sitting on a wheelchair in his room. One staff was feeding Resident 27. Resident 27 completed 100 percent (%) of his meal. During an observation on 11/3/2021 at 8:09 am, Resident 27 was lying in bed with G-Tube pump at bedside with Jevita 1.5 CAL bottle hanging on a pole and the pump was not running. In a concurrent interview, Licensed Vocational Nurse 2 (LVN 2) verified a total of 297 ml of Jevita 1.5 CAL was delivered to Resident 27. LVN 2 stated the daily feeding time to Resident 27 was scheduled from 6 PM to 2 AM to deliver 440 ml of Jevita 1.5 CAL as ordered. LVN 2 stated the licensed nurse from the previous shift should run the tube feeding for Resident 27 until 440 ml was delivered. LVN 2 stated Resident 27 did not receive then full amount of tube feeding of 440 ml of Jevita 1.5 CAL on 11/3/21. LVN 2 stated Resident 27 was at risk for weight loss and tube feeding was to provide the resident the necessary nutrition and hydration to promote physical and mental well being. A review of Resident 27's care plan revised 7/1/2021 indicated the resident is on G-tube feeding, was at risk for aspiration (accidental breathing in of food or fluid) dehydration (body loses too much water and other fluids) weight fluctuation, weight gain or weight loss. The care plan nursing interventions included to administer enteral feedings as ordered and to check feeding bag prior to end of shift to ensure adequacy and accuracy of volume. A review of the facility's Policy and Procedure titled Enteral Nutrition revised 2019, indicated, enteral nutrition will be provided to residents who are unable to meet their nutrition and hydration needs by oral administration, nursing will be responsible for tube feeding administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 20 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis on 11/1/2021 and 11/3/2021 in accordance to the facility assessment. This deficient practice had the potential to delay the provision of care nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Findings: a. During an observation on 11/1/2021 from 8:29 am to 1:40 pm, there were four (4) Certified Nursing Assistants (CNAs) in the East Wing, one (1) Licensed Vocational Nurse (LVN) and 1 Registered Nurse Supervisor (RN Supervisor) assigned for both the East and [NAME] Wing. There were two CNAs in the [NAME] Wing and 1 LVN. During a review of the Facility Census on 11/1/2021, indicated there were 82 residents, 40 residents in the East Wing and 42 residents in the [NAME] Wing. During an observation and interview on 11/1/2021 at 8:29 am in the [NAME] Wing, CNA 10 stated there were two CNAs assigned in the [NAME] Wing but the other CNA was on break at that time. CNA 10 and Activity Staff 1 were observed watching the residents outside the patio. During an observation on 11/10/2021 at 9:48 am in the East Wing, Resident 79 asked for water from CNA 1. During a concurrent observation and interview on 11/1/2021 at 10:34 am in the East Wing, Resident 79 did not get water. CNA 1 stated she informed the Activities Staff to bring water. CNA 1 added they were short staffed today. CNA 1 would usually have six (6) to seven (7) CNAs assigned in the East Wing but there were only 4 CNAs today for the 6 am to 2pm shift. During a concurrent review of the Nursing Staffing Hours and the Census and Direct Service Hours Per Patient Day, dated 11/1/2021 and interview with the Director of Nursing (DON) on 11/4/2021 at 4pm, DON stated the total actual CNA hours was 1.54 hours and the Total Direct Care Hours (TDCH) was 184 hours. DON stated TDCH divided by the facility census of 82 residents calculated to an actual Direct Hours Per Patient Day (DHPPD) of 2.42 hours. During an interview on 11/5/2021 at 9:34 am, the DON stated if there was a call off and no other staff could work for the available spot, staffing resources (Nursing Registry unit) will be called. DON stated he did not look for staff because it was in the middle of the night. DON stated if the charge nurse could not get another staff to work the staff would have to work as a team. b. A review of the Nursing Staffing Assignment for 11/3/2021 indicated there were seven (7) CNAs for the 6am to 2 pm shift. A review of the posted CNA assignment in the East Wing for 11/3/2021 indicated there were five (5) CNAs on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 21 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0725 During an observation on 11/3/2021 from 6:23 am to 1:28 pm, there were 5 CNAs in the East Wing. Level of Harm - Minimal harm or potential for actual harm During a review of the posted CNA assignment, dated 11/3/2021, the two CNAs (CNA 15 and CNA 16) included on the CNA assignment had a declaration submitted that they did not work on 11/3/2021. Residents Affected - Some A review of the Nursing Staffing Assignment for 11/3/2021, indicated there were two Activity Assistants included in the calculation of DHPPD. During an observation on 11/3/2021 at 9:54 am, Activity Staff 2 was providing activities to 10 residents in the outside patio (East Wing). A review of the Census and Direct Care Service Hours Per Patient Day indicated that only direct caregivers with a nursing services assignment shall be included in the DHPPD. A review of the facility's Census and Direct Service Hours Per Patient Per Day, dated 11/3/2021, indicated CNA 15 and CNA 16 were included in the computation of CNA Direct Service Hours, the actual CNA DHPPD was 2.36 and the actual total DHPPD was 3.14 hours. During an interview with the DON on 11/5/2021 at 9:38 am, DON stated the reason why we need sufficient staff was to be able to provide sufficient care for all the residents. A review of the Facility assessment dated [DATE], indicated the facility needed NHPPD 2.4 hours for CNAs and total of 3.5 hours NHPPD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 22 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post nursing staffing information on 11/4/2021. Residents Affected - Few This deficient practice had the potential for residents, resident representative and facility staff to not be aware of the nursing staffing at the facility. Findings: During an observation on 11/4/2021 at 3:56 pm, the posted nursing staffing information inside the front office was dated 11/2/2021. The front office was accessible to facility staff and/or visitors but it was not accessible to residents. During an interview on 11/4/2021 at 4:33 pm, the Director of Nursing (DON) stated the nursing staffing information should be posted daily and must be posted inside the front lobby or the staff break room. During an observation of the staff break room on 11/4/21 at 4:34 pm with the DON, there was no nursing staffing information posted inside the room. During an interview on 11/4/2021 at 4:36 pm, the DON stated the purpose of posting the nursing staffing information was to inform the staff, the residents and visitors of the daily nursing staffing at the facility. The DON stated the nursing staffing information will provide information if there was enough staff to provide care to residents for a particular day. A review of the facility's undated Policy and Procedure titled Federal Posting, indicated the facility will post Nursing Staffing Data on a daily basis per shift which includes the facility name, current date, resident census and the total number of actual hours worked by the Registered Nurses, Licensed Vocational Nurse and Certified Aides. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 23 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility staff failed to ensure a. Accurate and safe recording of controlled drugs, including the provision of routine and emergency medication and biologicals for one of two refrigerator emergency kits (e-kit) in the East Wing. b. The Floor Narcotic Release Log Stock was completed to ensure accurate accounting of controlled medications. These deficient practices had the potential for abuse and diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: a. During an observation of the e-kit in the refrigerator in the East Wing nurses station on 11/2/2021 at 12:28 p.m. with MDS Coordinator/ Registered Nurse (MDSC/RN), the e-kit was opened with yellow tag attached and Ativan ( anti anxiety medication) two milligrams ( mg- unit of measurement) was missing. During a concurrent interview, MDSC/RN stated, the pink slip of the Order Form was not dated and was checked at 10:00 pm for Resident 59 for Ativan 2mg Intramuscular ( IM) injection. The MDSC/RN stated, after the doctor has confirmed the order, the licensed nurse will inform the pharmacy the e- kit will be opened. The MDSC/RN stated the pharmacy should send the new e-kit the following day to replace the opened e kit. On 11/2/2021, at 12:47 p.m., during a record review of Resident 59's clinical record and interview with MDS assistant/Licensed Vocational Nurse (MDSA/LVN), she stated she did not see any new order for Ativan 2 mg IM for Resident 59. MDSA/LVN stated there was no order for Ativan 2 mg IM for Resident 59 for October 2021. MDSSA/LVN stated there were no documentation in the nurse's progress notes indicating Resident 59 was given Ativan 2 mg IM. During an interview with the facility's Director of Nursing (DON) on 11/2/2021, at 1:48 p.m., he stated Ativan 2 mg IM should not be given without physician's order and once the E-kit was opened, the pharmacy should replace it right away within 24 hours, per policy. During an interview with the DON on 11/4/2021, at 8:43 a.m., he stated when the doctor ordered for emergency medication from the e-kit, the licensed nurse should inform the pharmacy the e-kit will be opened, remove the medication log in the e-kit and the Order Form should be dated, timed and indicated the resident's name and when the e-kit was opened. The DON stated when the e-kit is intact, a red tag is attached and when the e kit was opened, a yellow tag is attached. The DON stated, once the e-kit is opened, the pharmacy with replace the whole e-kit. b. During a record review of the Floor Narcotic Release Log with LVN 2 on 11/3/2021, at 12:03 p.m., the following days were blank with no on-coming nurse's signatures and no outgoing nurse's signatures for 9/27/2021, 9/28/2021,10/4/2021, 10/5/2021, 10/21/2021, 10/23/2021, 10/29/2021, 10/30/2021, 10/31/2021, 11/1/2021. In a concurrent interview, LVN 2 stated every shift needs to do a narcotic count. LVN 2 stated blank boxes indicated licensed staff did not do the narcotic count on that day. LVN 2 stated, narcotics count was needed to ensure accuracy of the ordered narcotics and if there was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 24 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 discrepancy it can be reported to the DON immediately. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure titled Medication Storage In the Facility dated August 2014, indicated for controlled medication storage at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Emergency Pharmacy Service and Emergency Kits, is available on a 24 hours basis. Emergency needs for medication are met by issuing the facility's approved emergency medication supply or by special order from the provider pharmacy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 25 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' behavior and side effects for the use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for 5 of 38 sampled residents (Residents 6, 9, 43, 66 and 68) were monitored, as ordered. These deficient practices had the potential for inadequate monitoring for effectiveness, dose adjustments and adverse (harmful) consequences to the residents. Findings: 1. A review of Resident 68's admission Record indicated the resident was admitted to facility on 10/1/2021 with diagnoses including type II diabetes mellitus (high blood sugar), and arteriosclerotic heart disease (thickening and hardening of the walls of the coronary arteries). A review of Resident 68's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 68 required supervision to extensive assistance from staff for his activities of daily living. The MDS indicated Resident 68 received the following medications: insulin injection, antipsychotic, and antidepressant medications during the last 7 days or since admission/entry. A review Resident 68's recapitulated Physician Orders for the month of November 2021 indicated the following: - Monitor behavior for major depressive disorder manifested by (m/b) self expression of sadness, and tally wish yashmaks 0=absence 1=presence every shift for the use of Duloxetine. - Monitor behavior for major depressive disorder m/b panicky feeling causing stress, and tally with hashmarks 0=absence 1=presence every shift for the use of trazodone. - Monitor behavior for schizophrenia m/b extreme negative thoughts interfering with daily living and self-care, and tally with hashmarks 0=absence 1= presence every shift for the use of Seroquel. - Monitor anticoagulation medication for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifices, abnormal labs. Document: N, if monitored and none observed. Document: Y if monitored and any of the above observed. - Notify medical doctor (MD) and document in nurses' progress notes every shift for aspirin. - Monitor adverse side effect (ASE) for cognitive impairment and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for Parkinson syndrome (unchanging facial expression, drooling, tremors, rigidity) and tally with hashmarks 0=absence 1=presence every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 26 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0758 Level of Harm - Minimal harm or potential for actual harm - Monitor ASE for akathisia (motor restlessness, anxiety) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for tardive dyskinesia (involuntary movements of tongue, jaw, face and mouth) and tally with hashmarks 0=absence 1=presence every shift. Residents Affected - Some - Monitor for potential side effects of anti-depressant (duloxetine) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of anti-depressant (trazadone) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of antipsychotic (seroquel) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, shuffling gait, drooling, weight gain, photosensitivity. - Duloxetine capsule delayed release sprinkle 30 mg 1 capsule by mouth one time a day related to major depressive disorder, single episode, m/b self-expression of sadness. - Seroquel tablet 300 mg one tablet by mouth at bedtime related to schizophrenia m/b extreme negative thoughts interfering with daily living and self-care. - Seroquel tablet 50 mg one tablet by mouth two times a day related to schizophrenia m/b extreme negative thoughts interfering with daily living and self-care. - Trazodone 50 mg tablet one tablet by mouth at bedtime related to major depressive disorder, single episode, unspecified m/b panicky feeling causing stress. A review of Resident 68's Medication Administration Record for 10/1/2021 to 10/31/2021 with MDS assistant (MDSA) indicated on 10/1/2021 and 10/2/2021 the night shift staffs did not document monitoring of behavior for major depressive disorder, schizophrenia, cognitive impairment, Parkinson syndrome, akathisia, tardive dyskinesia, side effect of antidepressant duloxetine and trazadone, and antipsychotic seroquel. During a concurrent interview with MDSA on 11/3/2021 at 12:50 p.m., she confirmed the finding and stated staff did not document in the MAR as ordered on 10/1/2021 and 10/2/2021. 2. A review of Resident 6's admission Record indicated the resident was admitted to facility on 7/22/2020, and readmitted on [DATE], with diagnoses including paranoid schizophrenia (a type of schizophrenia (mental disorder) associated with feelings of being persecuted or plotted against) A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 8/8/2021 indicated the resident's cognitive (ability to understand) skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 6 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 27 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 6's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 6 was not performed as ordered. For 10/2/2021 night shift, monitoring behavior related to schizophrenia, cognitive impairment, adverse side effects for parkinsonism, akathisia, tardive dyskinesia, potential side effects for the use of haloperidol/zyprexa were not documented in the MAR. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day, as ordered. DON stated the MAR should be completed. 3. A review of Resident 9's admission Record indicated the resident was admitted to facility on 8/1/2019 and readmitted on [DATE], with diagnoses including schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 9's Minimum Data Set, dated [DATE], indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 9 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 9's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 9 was not performed as ordered. For 10/1/2021 and 10/2/2021 night shift, monitoring for side effects of zyprexa, adverse side effects for tardive dyskinesia, parkinsonism, akathisia, monitoring behavior for schizophrenia and monitoring for cognitive impairment was were not documented in the MAR. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day, as ordered. DON stated the MAR should be completed. 4. A review of Resident 43's admission Record indicated the resident was admitted to facility on 9/9/2021 with diagnoses including psychotic disorder (a condition that causes loss of reality). A review of Resident 43's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision to extensive assistance from staff for activities of daily living. The MDS indicated Resident 43 received antipsychotic and hypnotic medications during the last 7 days or since admission/entry. A review of Resident 43's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 43 was not performed as ordered. Entries on MAR were blank for the following: - On 10/1/2021 and 10/2/2021 (night shift) side effects for the use of depakote /zyprexa, monitor for adverse side effects akathisia/tardive dyskinesia, cognitive impairment, parkinsonism, psychosis, and psychotic delusion were not done. - On 10/3/2021 (morning shift) for monitoring for side effects for the use of depakote/zyprexa, monitoring for cognitive impairment and Parkinson and monitoring behavior for psychosis were not done. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 28 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0758 Level of Harm - Minimal harm or potential for actual harm a blank entry on the MAR it means the resident was not monitored for that day, as ordered. DON stated the MAR should be completed. 5. A review of Resident 66's admission Record indicated the resident was admitted to facility on 3/27/2014 and readmitted on [DATE], with diagnoses including paranoid schizophrenia. Residents Affected - Some A review of Resident 66's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 66 received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 66's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 66 was not performed as ordered. For 10/29/2021 day shift, monitoring for side effects of the use of risperdal/depakote/seroquel and monitoring for tardive dyskinesia were not done. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day as ordered. DON stated the MAR should be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 29 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: a. Ensure one expired vial of tuberculin (skin test to help diagnose tuberculosis [TB] infection) was not stored in the refrigerator to store medications for residents. This deficient practice had the potential for staff to use expired medication for the residents. b. Ensure one staff specimen of COVID-19 swab test was not stored in the refrigerator to store medication for residents. This improper storage practice had the potential to result in adverse consequences for the residents. Findings: a. During an observation of the medication storage refrigerator in the East Wing with Registered Nurse 1 (RN1) on [DATE] at 12:01 p.m., one vial of tuberculin had an open date of [DATE]. During a concurrent interview, RN1 stated the tuberculin vial was expired and should not be kept in the refrigerator and must be safely disposed. RN 1 stated, expired medication should be placed into the red plastic bag and should not be kept inside the refrigerator to store medications for residents During an interview with the Director of Nursing (DON) on [DATE], at 12:10 p.m., he stated the tuberculin vial must be removed from the refrigerator and disposed per policy. A review of the facility's Policy and Procedure, titled Guide for Special Handling of Medications revised [DATE], indicated Tubersol, Aplisol should be stored in the refrigerator and discarded 30 days after opening. A review of the facility's Policy and Procedure titled Skilled Nursing Pharmacy dated [DATE], indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. b. During an observation of the medication storage refrigerator in the East Wing with Registered Nurse 1 (RN1) on [DATE] at 12:01 p.m., one specimen of COVID 19 swab test dated [DATE] was inside the refrigerator. In a concurrent interview, RN 1 stated, the swab test belonged to a laundry personnel. RN 1 stated, the swab test was an old specimen and should not be in the resident's refrigerator to store medication. During an interview with the DON on [DATE], at 12:10 p.m., he stated the facility sends specimen to the laboratory timely and he doesn't know why the specimen was inside the refrigerator to store medications for residents. The DON stated the refrigerator was for resident only and staff specimen sample for Covid 19 swab test should not be stored in the refrigerator to store medication for residents. A review of the facility's undated Policy and Procedure titled Lab Specimen Collection indicated when physicians order laboratory tests, the specimens will be collected and placed in specimen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 30 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 refrigerator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 31 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow food sanitation and handling practices in accordance with professional standards for food service safety. The facility staff failed to label the date of one container with leftover tuna salad and one container with sliced ham. These deficient practices had the potential risk for food-borne illnesses (illness caused by eating or drinking contaminated food) to residents in the facility. Findings: During an observation of the facility's kitchen on 11/1/2021 at 8:25 am, one container of mixed tuna salad and one container of sliced ham were found inside one of the facility's refrigerator, without a date. In a concurrent interview, the facility's [NAME] 1 verified the findings and stated, the tuna salad was pre-mixed, ready to serve and the sliced ham was unused portion from the original package. [NAME] 1 stated he did not know when the tuna salad was mixed and when the sliced ham was opened. [NAME] 1 stated he did not know when and who placed the leftover tuna salad and sliced ham in the refrigerator. [NAME] 1 stated tuna salad containers should be labeled with the date prepared and the sliced ham container should be labeled with the date taken out from its original package. [NAME] 1 stated all leftover food should be labeled for infection control purposes and to prevent food-borne illness to residents. [NAME] 1 stated leftover food in the refrigerator without a date should be thrown away. During an interview on 11/1/2021 at 8:43 am, Dietary Supervisor (DS) stated, the kitchen staff should label food with the date it was opened or the date staff mixed the food before they put them inside the refrigerator. DS stated the purpose of labeling leftover food was to identify items for preparation time and when to discard the food for infection control and to prevent food-borne illness to residents. DS stated if spoiled food will be served to residents, they will get sick. A review of the facility's Policy and Procedure titled Left-over Food revised 2019, indicated, leftover food shall be refrigerated, dated, labeled and properly covered after meal service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 32 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: a. Ensure staff properly wear Personal Protective Equipment. Residents Affected - Some b. Complete the Visitor Screening For Covid-19 (Coronavirus disease 2019, is a respiratory illness that can spread from person to person) and Employee Screening For Covid-19, prior to entering the facility in October 2021. c. Disinfect the shower area and shower chair in between residents' use. These deficient practices had potential to spread infection to residents, staff, and visitors. Findings: a. During an observation on 11/4/2021 at 2:42 p.m. Restorative Nurse Assistant (RNA) was wearing a surgical mask below the nose. In a concurrent interview with the facility's Infection Preventionist Nurse (IPN), he stated, masks should be worn correctly and not worn below the nose, to provide protection. b. During a record review with IPN on 11/4/2021, at 2:42 p.m., The Visitor Screening For Covid-19 was not completed on 10/15/21 for one visitor, 10/19/21 for one visitor and on 10/24/21 for one visitor . There was no information on travel history, temperature upon entrance and exit, signs and symptoms (s/sx) related Covid-19, contact with confirmed Covid-19, education on Covid-19, visitor contact information, and visitor's signature. In a concurrent interview with IPN, he stated a staff is assigned in the front lobby to screen visitors. IPN cannot explain why there were no visitor screenings documented on 10/15/21, 10/19/21 and 10/24/21. The IPN stated screening for Covid-19 should be done and accurately documented. During a concurrent review of the Employee Screening Log for October 2021 indicated the screening was not completed for the following days: 10/1/2021, 10/4/2021, 10/9/2021, 10/10/2021, 10/23/2021, 10/24/2021, and 10/25/2021 - CNA 9 was not screened for s/s Covid-19 and contact with anyone with Covid-19. 10/23/2021- CNA 10 was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/19/2021- CNA 11 was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/1/2021, 10/2/2021, 10/8/2021, 10/9/2021, 10/16/2021 - LVN 4 was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/8/2021 and 10/12/2021 Rehabilitation Department 1 (Rehab D 1) was not screened for fever within 24 hours. 10/12/2021- CNA 12 was not screened for fever within 24 hours, for s/sx of Covid-19 and contact with anyone with Covid-19. 10/10/2021- LVN 5 did not sign the screening log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 33 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 10/10/2021- LVN 6 did not sign the screening log. Level of Harm - Minimal harm or potential for actual harm 10/9/2021- Laundry Personnel 2 (LP 2) did not sign the screening log. 10/9/2021- Activities Assistant (AA) was not screened for contact with anyone with Covid-19. Residents Affected - Some 10/2/2021 and 10/9/2021- CNA 13 was not screened for contact with anyone with Covid-19. 10/9/2021- CNA 1 was not screened for travel history, for s/sx of Covid-19 and contact with anyone with Covid-19. 10/5/2021- Dietary Aid (DA) was not screened for contact with anyone with Covid-19. 10/1/2021 and 10/4/2021- House Keeping1 (HK1)not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/1/2021- RNA was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/1/2021 - CNA 14 not screened for s/sx of Covid-19 and contact with anyone with Covid-19. A review of the facility's Policy and Procedure, titled COVID-19 Visitations dated 9/7/2021, indicated the facility will actively screen and will restrict visitation by those who meet the following criteria: . Signs and symptom of Covid-19, such as fever or chills, cough, shortness of breath, sore throat, headache, muscle or body ache, fatigue, new loss of taste or smell, congestion, nausea or vomiting, and/or diarrhea. . In the last 14 days, has had contact with someone with a diagnosis of Covid-19, or under investigation for Covid-19, or are ill with respiratory illness. . Unvaccinated visitors returning from international trip are required to quarantine for 14 days. . Provide proof of vaccination (must be fully vaccinated) or testing results. This will be documented as part of the screening process. For those individuals that do not meet the above criteria, their entry may be restricted. The facility screens and documents every individual entering the facility (including staff) for Covid-19 symptoms. Proper screening includes temperature checks (Employee Screening Log/Visitors Screening Log). c. During an observation 11/3/2021 at 9:07 am, Certified Nursing Assistant 9 (CNA 9) just finished providing a shower to Resident 30, wheeled the resident out of the shower then went back inside to pick up dirty towels from the floor. CNA 9 did not disinfect the shower area and the shower chair after Resident 30's use. During an observation on 11/3/2021 at 9:09 am, CNA 2 assisted Resident 10 inside the shower room using the wheelchair, assisted him to sit on the shower chair and proceeded to provide shower to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 34 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 resident. Level of Harm - Minimal harm or potential for actual harm During an observation on 11/3/2021 at 9:22 am, CNA 2 completed assisting Resident 10 with shower and assisted the resident back to his room using the wheelchair. Residents Affected - Some During an interview on 11/3/2021 at 9:34 am, CNA 2 stated she washed the shower area and the shower chair with water before and after using the shower area. CNA 2 stated she did not know what to use to disinfect the shower chair. A review of the Local Public Health Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities updated 10/1/2021, indicated environmental cleaning recommendations should be followed where applicable before and after patient care. This includes properly disinfecting shared equipment, e.g blood pressure cuffs and pulse oximeters before and after vital checks. Routine cleaning and disinfecting procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital grade disinfectant to frequently touched surfaces). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 35 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 40 resident rooms did not accommodate more than four residents per room. Findings: On 11/1/2021, the Administrator (ADM) submitted a written room waiver request for three resident rooms, which had five beds In each room. A review of the letter for. waiver indicate the following Room number Number of Beds Square feet (sq. fl) 6 5 513.00 15 5 400.00 26 5 412.00 The room waiver request Indicated the residents' needs were accommodated and there were no adverse effects to the health, safety, and welfare to the residents occupying. these rooms. The maximum number of beds allowed In a multiple resident bedroom should be no more than four beds per room. During the initial tour of the facility conducted on 11/1/2021 at 8:38 a.m., Rooms, 6, 15, and 26 each had five beds in the rooms. During the recertificatlon survey from 11/1/2021 to 11/5/2021, most of the residents in the facility were ambulatory and did not have difficulty getting in and out of their rooms. The nursing staff had full access to provide treatment, administer medications, and assist residents to perform their Individual routine activities of [NAME] living (ADLs, such as transferring, dressing, eating, and toileting). On 11/3/2021 at 8:18 a.m., during an interview with Certified Nurse Assistant 8 (CNA 8), she stated there was enough space to care for the resident in room [ROOM NUMBER]. On 11/5/2021 at 8:18 a.m., during an interview Resident 20, she stated her room had enough space and there was no concern to walk around. On 11/5/2021 at 8:25 a.m., during an interview Resident 26, while on his wheelchair, he was able to self propel in the room easily and had no concern. The department is recommending the room waiver requested by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 36 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 resident bedrooms measure at least 100 square feet (sq. fl) per resident In a single resident room for four of 12 single rooms. Findings: On 11/1/2021, the Administrator submitted a written room waiver request for four single bedrooms, which Included the square footage of each room. A review of the waiver letter Indicated the following: Room number Number of Beds Square Foot 4 1 74.40 5 1 74.40 16 1 67.89 17 1 67.89 The room waiver request indicated the residents' needs were accommodated and there were no adverse effects to the health, safety, and welfare to the residents occupying these rooms. The maximum number of beds allowed In a multiple resident bedroom should be no more than four beds per room. The minimum square footage requirement for a single bedroom should be at least 100 square feet. During the survey period from 11/1/2021 to 11/5/2021, rooms 4, 5, 16, and 17, had only one bed. The residents were ambulatory and were able to get in and out of their rooms without any difficultly. The nursing staff had access to provide treatment, administer medications, and assist with residents' individual routine care and activities of [NAME] living (ADLs. such as transferring, dressing, eating, and toileting). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 37 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 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 0913 Provide bedrooms that have direct access to an exit hallway. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to have bedrooms that had direct access to an exit corridor for four of 40 bedrooms in the facility. Residents Affected - Some Findings: During initial tour of the facility on 11/1/2021 at 8:38 a.m., Rooms 4, 5, 16, and 17 did not have direct access into a corridor. Residents in rooms 4, 5, 16, and 17 had to enter other resident's rooms to get to the nearest exit corridor. During the survey period from 11/1/2021 to 11/5/2021 the residents were ambulatory. The nursing staff had access to provide treatment, administer medications and assist with residents' individual routine care and activities of daily living (ADLs, such as transferring, dressing, eating, and toileting). During the survey period from 11/1/2021 to 11/5/2021, a room variance for the residents' bedrooms received on 11/1/2021 indicated the residents' needs were accommodated and there were no adverse effects to the health, safety, and welfare of the residents occupying these rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 38 of 38