Health inspection·July 14, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment and care screening tool) assessment for one of one sampled resident (Resident 3) was transmitted timely in accordance with the facility policy. Residents Affected - Few This deficient practice resulted to a late transmission of MDS assessment to Centers of Medicare and Medicaid (CMS) Internet Quality Improvement and Evaluation System (IQIES), which had the potential to affect the facility's quality care measure monitoring data. Findings: A review of the facility's admission Record indicated Resident 3 was readmitted to the facility on [DATE]. A review of Resident 3's latest quarterly MDS indicated it was completed on 5/4/2023. During a concurrent record review and interview and on 7/13/2023, at 10:24 am, the Director of Nursing (DON) stated, Resident 3's MDS was not submitted to CMS within time frame, as required by regulation. The DON stated Resident 3's MDS was completed on 5/4/2023 and the facility forgot to submit it to CMS within 14 days after completion, which should have been before 5/28/2023. The DON stated the facility submitted Resident 3's MDS to CMS today, 7/13/2023, and it was delayed. The DON stated it was important to submit the resident's MDS on time so CMS could be made aware of the overall and updated health condition of each resident and facility could be paid accordingly. A review of the facility's policy and procedure titled, MDS Tracking and Submission, revised 5/2023, indicated all MDS time frames will be accurate for change of condition, annual and quarterly reviews. Once assessment is completed it must be submitted within 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555850 If continuation sheet Page 2 of 7 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 555850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Hospital Med Ctr Dp/Snf 100 S Raymond Ave Alhambra, CA 91801 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 interview and record review, the facility failed to complete and post the nursing staffing data at the beginning of the shift on 7/11/2023, 7/12/2023, and 7/13/2023 in accordance with the facility policy. Residents Affected - Few This deficient practice resulted to the total number of staff and the actual hours worked by the staff not readily accessible to residents and visitors. Findings: During a record review of a facility form posted on the entrance wall of the facility, titled, Daily Staffing (Direct Care Service Hours Per Patient Day [DHPPD], workload monitoring system used to calculate nursing hours per direct caregiver), on 7/11/2023 at 11:30 am, indicated a resident census of 23. The form included the names of the licensed nurses (LN) and certified nurse assistants (CNA) however their hours were blank. During a record review of a facility form posted on the entrance wall of the facility, titled, Daily Staffing, dated 7/12/2023, on 7/12/2023 at 11:30 am, indicated a resident census of 23. The form included the names of the LN and CNA, however their hours were blank. During a record review of a facility form titled, Daily Staffing, on 7/13/ 2023, at 10:00 am, information posted on the entrance wall of the facility, dated 7/13/2023, indicated a resident census of 23. The form included the names of the LN and CNA, however their hours were blank. During a concurrent record review of the Daily Staffing, dated 7/13/2023, and interview with the Director of Nursing (DON) on 7/13/2023, at 10:15 am, the DON stated, I filled out the form and entered the names of licensed and CNAs, but not their hours of work. I posted the updated staffing information in the morning, but never the hours for morning shift, only the names because of possible changes. The DON further stated, The staffing information was not updated until the end of each shift, and the purpose of the form was for visitors and staff to see who is on schedule, this is the way I have always completed the form. During a review of the facility's policy and procedure (P&P) titled, Daily Staffing, dated 9/2017, indicated that the facility will post daily, at the beginning of each shift, the facility specific shift schedule for the 24-hour period, including the number and categories of nursing staff as well as the total number of hours worked by licensed and unlicensed staff who are directly responsible for resident care. The daily staffing posting will include: (2) Staffing posting for all two shifts on a daily basis that includes the total number and the actual hours worked by the following categories of licensed and unlicensed staff that are directly responsible for resident care per shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555850 If continuation sheet Page 3 of 7 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 555850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Hospital Med Ctr Dp/Snf 100 S Raymond Ave Alhambra, CA 91801 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper food sanitation and handling practices by failing to: Residents Affected - Some 1. Label and date 16 to-go boxes of left-over food cooked/prepared on 7/10/2023 stored in the kitchen refrigerator. 2. Place two bags of Toasted Pounded Young Rice in freezer per manufacturer's instruction. The two bags of Toasted Pounded Young Rice were observed in the kitchen dry storage room at room temperature and unlabeled. These failures had the potential to result in food-borne illnesses to the residents. Findings: During a concurrent interview with the Registered Dietitian 1 (RD 1) and observation in the facility's kitchen on 7/10/2023, at 8:39 am, inside the refrigerator were 16 to-go unlabeled disposable foam boxes containing cooked beef, chopped chicken meat, zucchini, carrots and rice. The RD 1 stated, These 16 to-go boxes were left-over food from last night (7/10/2023). RD 1 stated there was no label on these boxes indicating the date when these foods were cooked. RD 1 stated the kitchen staff who put the boxes inside the refrigerator should have labeled each box with the expiration date so other staff would know to ensure expired foods will not be served to the residents. RD 1 stated this measure was to prevent food borne illness like fever, diarrhea, and vomiting. During an interview on 7/11/2023, at 8:45 am, Dietary Assistant 1 (DA 1) stated, 16 boxes of food were left over from yesterday's dinner. DA 1 stated all foods inside refrigerator should have been labeled with expired date so the kitchen will not serve expired food to residents to prevent food borne illness. During a concurrent interview with the kitchen's Lead [NAME] (LC) and observation on 7/11/2023, at 9 am, in the facility's kitchen dry storage room, two bags of Toasted Pounded Young Rice were placed on the dry storage shelf at room temperature. There were printed instructions on the upper left corner of these two bags, which indicated keep frozen. These two bags were out of their original package and did not have an expiration date on the packages. LC stated, these two bags should not be stored on the dry storage shelf and should follow manufacture instruction to keep them frozen in the freezer. LC stated, once food packages were removed out from their original package, they should be labeled and dated either with the open date or expiration date, so the kitchen does not serve expired food to residents. LC stated, The facility does not serve bad food to the residents and staff for food safety reason. During a review of the facility's policy and procedure titled, Food Storage, reviewed 2/2020, indicated food items will be stored appropriately to ensure product safety and quality. Carry-over foods are cooled and is covered, labeled, and dated when stored in the designated area. During a review of the facility's policy and procedure titled, Food Receiving, Storage and Discard, revised 4/2021, indicated all food should be wrapped, labeled, and dated before placed in storage. Check expiration date for food items in its original packaging, if it is not visible, rewrite the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555850 If continuation sheet Page 4 of 7 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 555850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Hospital Med Ctr Dp/Snf 100 S Raymond Ave Alhambra, CA 91801 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 expiration date on the outer box. Food should be stored according to the temperature required. 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: 555850 If continuation sheet Page 5 of 7 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 555850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Hospital Med Ctr Dp/Snf 100 S Raymond Ave Alhambra, CA 91801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard precautions (infection prevention practices that apply to all resident care) were followed for one of 17 sampled residents (Resident 12) when Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 2 (RN 2) did not perform hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) before entering the resident's room and during care. Residents Affected - Few This failure had the potential to cause and/or spread infections, which can cause harm and negatively affect Resident 12's quality of life. Findings: A review of Resident 12's admission Record indicated Resident 12 was admitted on [DATE], and readmitted on [DATE], with diagnoses including respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), ventilator (machine that moves air in and out of the lungs) dependent, tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and recurrent cerebrovascular accident (blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel causing brain cells to die). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 4/5/2023, indicated Resident 12 was comatose (persistent vegetative state/no discernible consciousness). The MDS indicated Resident 12 was assessed as totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. During a concurrent observation in Resident 12's room and interview on 7/11/2023, at 9:57 am, LVN 1 was observed touching Resident 12's trach tube (a plastic tube placed in a surgically created opening in the windpipe to keep it open) without performing hand hygiene or changing gloves after touching Resident 12's ointment. LVN 1 stated, Hand washing and changing gloves should be performed before touching Resident 12's trach tube. Doing the wrong practice could cause and/or spread infection. During a concurrent observation and interview on 7/12/2023, at 1:25 pm with RN 2 outside resident 12's room, RN 2 went inside Resident 12's room and put on gloves without performing hand hygiene. RN 2 stated, she forgot to do hand hygiene. RN 2 added, Hand hygiene is essential during resident care to prevent spread of diseases. During an interview on 7/12/23 at 2:43 pm with Infection Preventionist (IP), IP stated, The staff follows standard precaution when entering residents' room. IP stated, Hand hygiene should be performed before and after entering a resident's room and during care when changing task. During an interview on 7/14/23 at 8:38 am with the Director of Nurses (DON), the DON stated, Nurses are expected to do hand hygiene before entry and before going out a resident's room. The DON added, Nurses are also expected to do hand hygiene and change gloves when touching different surfaces in residents' room. A review of the facility's policy and procedure titled, Hand Hygiene, dated 1/2023, indicated gloves should be used as an adjunct (supplementary), not a substitute for hand hygiene. Hands must be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555850 If continuation sheet Page 6 of 7 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 555850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Hospital Med Ctr Dp/Snf 100 S Raymond Ave Alhambra, CA 91801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cared for by hand washing with soap and water or by hand antisepsis (prevention of infection by inhibiting the growth and multiplication of germs) with alcohol-based hand rubs: a) Before and after resident contact b) After contact with a source of microorganism (body fluids and substances, mucous membranes, nonintact skin, inanimate objects that are likely to be contaminated), c) After removing gloves. A review of the facility's policy and procedure titled, Sub-Acute Infection Control Policies, dated 9/2021, indicated: a) All patients will be always under standard precautions, b) Each staff member assigned in the unit is responsible for ensuring that infection prevention and control procedures are performed c) Hand hygiene techniques are to be performed according to established hospital guidelines including before and after patient contact, d) All used equipment must be considered contaminated and is handled in a safe manner to protect other patients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555850 If continuation sheet Page 7 of 7