Health inspection·December 15, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] with diagnoses that included traumatic brain injury (brain injury usually results from a violent blow or jolt to the head or body that affects the persons mood and behavior such as aggression, combativeness, or other unusual behavior) and schizoaffective disorder. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand others and express own ideas and wants. The MDS indicated Resident 2 was able to walk 150 feet distance without the need of an assistive device, and without impaired range of motion (limit to which a part of the body can be moved) on both upper and lower extremities. A review of Resident 2's History and Physical (H&P, a document that contains the physician's examination of a resident) from General Acute Care Hospital (GACH), dated 10/10/23, indicated Resident 2 was admitted in the psychiatric (a unit in the hospital that focus patients with mental and behavioral care) unit of the hospital due to aggressive behavior. A review of Resident 2's Nursing Home Visit, dated 10/30/23, indicated Resident 2's initial H&P upon admission to the facility with diagnoses included recent hospitalization due to aggressive behavior. A review of Resident 2's COC (Change of Condition/INTERACT ASSESSMENT FORM SBAR (Situation Background Assessment and Recommendation -a communication tool that allows health professionals to communicate clearly about the resident's condition) dated 10/31/23, at 3:35 AM, indicated that a staff saw Resident 2 pounding at Resident 1 because Resident 2 thought that Resident 1 was raping him for some reasons. A review of Resident 1's COC /INTERACT ASSESSMENT FORM SBAR dated 10/31/23, timed at 6:53 AM, indicated, on 10/31/23 at 3:30 AM, a CNA was calling for help in Resident 1's room when the CNA found Resident 2 pounding on Resident 1. A head-to-toe assessment was conducted and noted Resident 1 with left eyebrow abrasion measuring 3 cm (centimeter- a unit of measurement) x 0.5 cm with slight bleeding and right eyebrow abrasion measuring 0.5 cm x 0.5 cm and left forehead swelling. During a review of the GACH record, dated 10/31/23, timed at 12:33 PM, indicated Resident 1 was admitted to the ER (Emergency Room) due to headache, chest pain and laceration (deep cut) of the forehead measuring three centimeter in length, that required three sutures (stitches on the skin) and given Morphine Sulfate (MS- a medication given for severe pain). The GACH record indicated Resident 1 reported being assaulted by another resident at the nursing facility and was punched on the left side of the head in the middle of the night. During an interview on 12/4/23, at 3 PM with Resident 1's Family (FAM), FAM stated, she was informed by Resident 1 that on 10/31/23 at 3:30 AM, he was beaten up by another resident and was bleeding on his head with left side eye brown wound. The FAM also added, Resident 1 stated he was traumatized, could not stop shaking and had muscle spasm after the incident happened. During an observation conducted on 12/15/23 at 12:56 PM, Resident 1 and Resident 2's rooms had a shared/common restroom located between each of their rooms. During an interview on 12/15/23 at 1:30 PM with Registered Nurse Supervisor (RNS), RNS stated, RNS stated that she did not know Resident 2 was admitted to the facility with history of diagnosed schizophrenia disorder related to aggressive behaviors. The RNS stated, she did not read Resident 2's H&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and record from GACH. The RNS stated, she should have reviewed Resident 2's H&P, diagnoses, and orders to make sure the right care plan and care was developed and provided to Resident 2. The RNS stated residents with history of aggressive behaviors must be monitored closely upon admission to prevent potential accidents and abuse. During an interview on 12/15/23 at 2:20 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she usually took care of new resident's admission, including Resident 2. LVN 2 added, she received a package which included Resident 2's H&P, diagnoses, progress notes, and the physician orders upon admission. LVN 2 stated, she created Resident 2's baseline care plan and would request further physician orders if needed. LVN 2 stated, a baseline care plan was very important because it helped the nursing staff to provide Resident 2 with the right care based on his diagnoses. During a concurrent interview and record review on 12/15/23 at 2:30 PM with LVN 2, Resident 2's medical record was reviewed. LVN 2 stated, per H&P, Resident 2 was admitted to the hospital prior to transferring to the facility with chief complaint of aggressive behavior. LVN 2 stated his history of aggressive behaviors should have been addressed in the baseline care plan with strict monitoring for the safety of staffs and other residents per protocol. LVN 2 added, without the baseline care plan for aggressive behavior, the staffs were not aware, and the resident was not properly monitored so there was a high risk for resident-to-resident abuse. LVN 2 stated, she must have overlooked Resident 2's H&P and did not thoroughly review Resident 2's admission package and records from GACH so that the physical abuse and incident between Resident 1 and Resident 2 could have been prevented. During an interview on 12/15/23 at 4:05 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated to keep the residents safe, CNA 1 stated all CNAs were responsible to visually monitor and document their assigned residents' whereabout every 2 hours. During an interview on 12/15/23 at 4:22 PM with CNA 3, CNA 3 stated, it was important to monitor the residents every 2 hours and document on time to make sure that residents are okay. During an interview with Director of Staff Development (DSD) on 12/15/23 at 4:45 PM, the DSD stated, LVNs and the RNS should be checking and reminding the CNAs to document on time for their tasks and residents' whereabout because conducting timely monitoring and documentation was important to keep track of the resident's whereabout and monitor the resident behavior to prevent physical abuse. During an interview on 12/15/23 at 5 PM with LVN 1, LVN 1 stated that she was not aware that Resident 2 had an angry outburst because she did not read Resident 2's H&P and she was not informed by the other staffs. LVN 1 stated, she should have reviewed all new residents' admission information before taking care of them. During an interview on 12/15/23 at 5:42 PM with the Director of Nurses (DON), DON stated, according to the facility's policy, residents in the facility are monitored every 2 hours by the CNAs. DON stated that monitoring was important in preventing acts of abuse. DON stated that monitoring was even more important on new residents with history of aggressive behavior. During an interview on 12/15/23 at 6 PM with the Director of Nurses (DON), DON stated, nursing staffs including the admitting nurse, RNS, LVN charge nurse were expected to review new resident's admitting package before taking care of them. DON stated, RNS and LVN charge nurse should know how to do the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review on 12/15/23 at 6:00 PM with the DON, Resident 2's Documentation Survey Report for monitoring resident location every 2 hours was reviewed. The record indicated, there were missing entries in the CNA's monitoring log indicated that Resident 1 and Resident 2 were not monitored every two hours consistently on 10/30/23 at 4 PM, 6 PM, 8 PM, 10 PM, and on 10/31/23 at 12 AM, 2 AM, 4 AM. The DON stated that if there was no documentation, the facility staffs did not provide supervision to the residents at those times. DON stated that with enough supervision and proper monitoring, Resident 1's abuse on 10/31/23, at 3:35 AM could have been prevented. During an interview on 12/15/23 at 6:30 PM with the Administrator (ADM), the ADM stated, if the documentation was blank, it meant the facility staffs did not do their job. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated the facility will provide a safe environment as free of injury to prevent resident to resident abuse by each resident admitted will be assessed for aggressive behavior or potential for striking out as being abusive to others (patient and staff), a plan of care will be implemented to address and prevent aggressive behaviors. A review of the facility's policy titled, Routine Resident Checks, revised July 2013, indicated that routine checks of residents are done to maintain resident safety and well-being. A review of the facility's policy and procedure titled, Prevention of Resident Abuse and Treatment, revised 12/7/21, indicated that monitoring of residents shall be the responsibility of, but not limited to, direct caregivers, Charge Nurses, Nursing Supervisors, and the interdisciplinary team. The policy and procedure also indicated that samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are residents with history of aggressive behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and provide the necessary behavioral health care and services for one of three sampled residents (Resident 2) with diagnosis of schizoaffective disorder (a chronic and severe mental disorder that affects how a person thinks, feels, behaves and experience psychosis [behavioral symptoms that affect the mind, and loss of contact with reality]) manifested by history of increase agitation, aggressive behavior toward staff, and paranoid delusion (profound fear and loss of the ability to tell what's real and what's not real) believing other people are against him causing outburst of anger as indicated in the facility's policy and procedure by failing to: 1. The Licensed Vocational Nurse (LVN) did not appropriately assess and monitor Resident 2's aggressive behaviors. 2. Administer Ativan (medication used to relieved anxiety [fear of the unknown]) and Haldol (a medication used to control mood and behavior) as ordered by the physician for Resident 2 on 10/30/23 with history of angry outburst. 3.The Certified Nursing Assistants (CNA) did not consistently monitor Resident 2 for safety whereabouts every two hours as indicated in the facility's policy and procedure. 4. A care plan was not developed to address and provide interventions on how to manage the paranoid and delusional behavior of the Resident 2. 5. Review Resident 2's clinical records prior to the admission to the facility and when admitted to the facility on [DATE] was not reviewed by the facility to ensure Resident 2 was properly placed in the facility. As a result of this deficient practice, Resident 2 entered a room adjacent to him without supervision and pounded on Resident 1's head with a delusion thought that Resident 1 was raping him (13 hours after Resident 2 was admitted to the facility). Resident 1 reported feeling traumatized and sustained a laceration (deep skin cut) of the left forehead and was hospitalized for suture placement above the left eyebrow from being pounded in the head. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses that included polyneuropathy (a nerve damage that causes pain, decreased ability to move and feel because of nerve damage) and dementia (a brain disorder that causes gradual decline in memory and thought process). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 11/7/23, indicated Resident 1 had the ability to understand others and express own ideas and wants, that required partial assistance (helper does less than half the effort) to walk ten feet distance, transfer to and from a bed to a chair, and changing position from sitting to standing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's COC /INTERACT ASSESSMENT FORM SBAR dated 10/31/23, timed at 6:53 AM, indicated, on 10/31/23 at 3:30 AM, a CNA was calling for help in Resident 1's room when the CNA found Resident 2 pounding on Resident 1. A head-to-toe assessment was conducted and noted Resident 1 with left eyebrow abrasion measuring 3 cm (centimeter- a unit of measurement) x 0.5 cm with slight bleeding and right eyebrow abrasion measuring 0.5 cm x 0.5 cm and left forehead swelling. Residents Affected - Few During a review of the GACH record, dated 10/31/23, timed at 12:33 PM, indicated Resident 1 was admitted to the ER (Emergency Room) due to headache, chest pain and laceration (deep cut) of the forehead measuring three centimeter in length, that required three sutures (stitches on the skin) and given Morphine Sulfate (MS- a medication given for severe pain). The GACH record indicated Resident 1 reported being assaulted by another resident at the nursing facility and was punched on the left side of the head in the middle of the night. During an interview on 12/4/23, at 3 PM with Resident 1's Family (FAM), FAM stated, she was informed by Resident 1 that on 10/31/23 at 3:30 AM, he was beaten up by another resident and was bleeding on his head with left side eye brown wound, which resulted in a 4-day hospital stay. The FAM also added, Resident 1 stated he was traumatized, could not stop shaking and had muscle spasm after the incident happened. A review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] with diagnoses that included traumatic brain injury (brain injury usually results from a violent blow or jolt to the head or body that affects the persons mood and behavior such as aggression, combativeness, or other unusual behavior) and schizoaffective disorder. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand others and express own ideas and wants. The MDS indicated Resident 2 was able to walk 150 feet distance without the need of an assistive device, and without impaired range of motion (limit to which a part of the body can be moved) on both upper and lower extremities. A review of Resident 2's History and Physical (H&P, a document that contains the physician's examination of a resident) from General Acute Care Hospital (GACH), dated 10/10/23, indicated Resident 2 was admitted in the psychiatric (a unit in the hospital that focus patients with mental and behavioral care) unit of the hospital due to aggressive behavior. A review of Resident 2's Nursing Home Visit, dated 10/30/23, indicated Resident 2's initial H&P upon admission to the facility with diagnoses included recent hospitalization due to aggressive behavior. A review of Resident 2's COC (Change of Condition/INTERACT ASSESSMENT FORM SBAR (Situation Background Assessment and Recommendation -a communication tool that allows health professionals to communicate clearly about the resident's condition) dated 10/31/23, at 3:35 AM, indicated that A staff saw Resident 2 pounding at Resident 1 because Resident 2 thought that Resident 1 was raping him for some reasons. A review of Resident 2's Order Summary report, dated 10/30/23, indicated the physician ordered to administer Haloperidol to Resident 2 for behavior problem related to paranoid delusion believing other people are against him causing outburst of anger, Haloperidol 5 mg (milligram, a unit of weight measurement) to be given by mouth three times a day for schizoaffective disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 2's Medication Administration Record, indicated the Haloperidol was ordered on 10/30/23 at 4PM. The MAR indicated Resident 2 was not administered Haldol on 10/30/23. The MAR indicated Haldol was first administered to Resident 2 on 10/31/23 at 8 AM, (five hours after Resident 2 pounded Resident 1 on the head on 10/31/23 at 3:30 AM). A review of Resident 2's Order Summary Report, on 10/30/23 the physician ordered to administer Ativan to Resident 2 for increase agitation, aggressive behavior toward staff, The record also indicated; Ativan 1 mg was ordered to give by month every 6 hours as needed. A review of Resident 2's MAR, indicated, Ativan was ordered on 10/30/23 at 4PM, The MAR indicated Resident 2 was not administered Ativan as needed on 10/30/23. A review of Resident 2's Order Summary Report, dated 10/30/23, indicated Resident 2 the physician's ordered the staff to monitor behavior every shift related to agitation, aggressive toward staffs, and delusion and document hashmarks of 0 (meaning. no agitation, no delusion episode) or 1 (meaning, agitation or delusion presented) with the start date of 10/30/23. A review of Resident 2's Medication Administration Record, dated 12/28/23, indicated, during 11 PM on 10/30/23 to 7 AM on 10/31/23, night shift Licensed Vocational Nurse (LVN) documented 0 (no agitation or aggressive behavior and no delusion presented), following the abusive event on 10/31/23 at 3:35 AM. During an observation conducted on 12/15/23 at 12:56 PM, Resident 1 and Resident 2's rooms had a shared/common restroom located between each of their rooms. During an interview on 12/15/23 at 1:30 PM with Registered Nurse Supervisor (RNS), RNS stated, RNS stated that she did not know Resident 2 was admitted to the facility with history of diagnosed schizophrenia disorder related to aggressive behaviors. The RNS stated, she did not read Resident 2's H&P because she was not the admitting nurse. The RNS stated, she should have reviewed Resident 2's H&P, diagnoses, and orders to make sure the right care be provided to Resident 2. The RNS stated residents with history of aggressive behaviors must be monitored closely upon admission to prevent potential accidents and abuse. During a concurrent interview and record review on 12/15/23 at 2:30 PM with LVN 2, Resident 2's medical record was reviewed. LVN 2 stated, per H&P, Resident 2 was admitted to the hospital prior to transferring to the facility with chief complaint of aggressive behavior. LVN 2 stated his history of aggressive behaviors should have been addressed in the baseline care plan with strict monitoring for the safety of staffs and other residents per protocol. LVN 2 added, without the baseline care plan for aggressive behavior, the staffs was not be aware, and the resident was not be properly monitored so there would be a high chance of resident-to-resident abuse. LVN 2 stated, she must have overlooked the H&P and added, it was very important to review Resident 2's admission package because the abuse and incident should have been prevented. During an interview on 12/15/23 at 4:05 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the facility's policy and procedure indicated to keep the residents safe, the CNA's will visually monitor the residents for safety every 2 hours. CNA 1 stated all CNAs were responsible to document their assigned residents' whereabout every 2 hours for safety. During an interview with Director of Staff Development (DSD) on 12/15/23 at 4:45 PM, the DSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, LVNs and the RNS should had been checking and reminding the CNAs to document on time for their tasks and residents' whereabout because conducting timely monitoring and documentation is important to keep track of residents and prevent accidents. During an interview on 12/15/23 at 5 PM with LVN 1, LVN 1 stated she was familiar with the altercation between Resident 1 and Resident 2. LVN 1 stated that she was not aware that Resident 2 had an aggressive behavior because she did not read Resident 2's H&P. LVN 1 stated, she should have reviewed all new residents' admission information before taking care of the resident. During an interview on 12/15/23 at 5:42 PM with the Director of Nurses (DON), DON stated, according to the facility's policy, residents in the facility are monitored every 2 hours by the CNAs. DON stated that monitoring the residents with aggressive behavior was important in preventing acts of abuse. DON stated that monitoring was even more important on new residents with history of aggressive behavior. During an interview on 12/15/23 at 6 PM with the Director of Nurses (DON), DON stated, nursing staffs including the admitting nurse, RNS, LVN charge nurse were expected to review new resident's admitting package before taking care of them. DON stated, RNS and LVN charge nurse should know how to do the care plan. During an interview and concurrent record review on 12/15/23 at 6:00 PM with the DON, Resident 2's Documentation Survey Report for monitoring resident location every 2 hours was reviewed. The record indicated, there were missing entries in the CNA's monitoring log indicated that Resident 1 and Resident 2 were not monitored every two hours consistently on 10/30/23 at 4 PM, 6 PM, 8 PM, 10 PM, and on 10/31/23 at 12 AM, 2 AM, 4 AM. DON stated that if there was no documentation, the facility staffs did not provide supervision to Resident 2 at those times. DON stated that with enough supervision and proper monitoring, Resident 1's incident of being pounded on the head by Resident 2 on 10/31/23, at 3:35 AM could have been prevented. During an interview on 12/15/23 at 6:30 PM with the Administrator (ADM), the ADM stated, if the documentation was blank, it meant the facility staffs did not do their job. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated the facility will provide a safe environment as free of injury to prevent resident to resident abuse by each resident admitted will be assessed for aggressive behavior or potential for striking out as being abusive to others (patient and staff), a plan of care will be implemented to address and prevent aggressive behaviors. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated facility shall institute procedures that allows identification, correction, and intervention in situations in which abuse, neglect of resident is more likely to occur. Areas of identification, correction, and intervention may include but not limited to, identification of residents with potential for behavior symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning, and monitoring. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated facility shall ensure care planning for residents with needs and behaviors which might lead to conflict or neglect. Samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are Residents with history of aggressive behavior. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Residents with possible needs and potential for behavioral symptoms and manifestations that may lead to conflict and anger, or neglect shall be identified through comprehensive assessments, initially upon a resident's admission and continuously thereafter. A review of the facility's policy titled, Routine Resident Checks, revised July 2013, indicated that routine checks of residents are done to maintain resident safety and well-being. A review of the facility's job description for CNA's, dated 1/27/22, indicated it is the responsibility of the CNA to make actual resident rounds, providing care, and monitoring. It also indicated that it is the responsibility of the CNA to record care as given. A review of the facility's policy and procedure titled, Prevention of Resident Abuse and Treatment, revised 12/7/21, indicated that monitoring of residents shall be the responsibility of, but not limited to, direct caregivers, Charge Nurses, Nursing Supervisors, and the interdisciplinary team. The policy and procedure also indicated that samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are residents with history of aggressive behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555755 If continuation sheet Page 9 of 9