Other·October 9, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Recertification survey. Representing the Department of Public Health: Health Facilities Evaluator, Nurse: 36385, RN, HFEN Health Facilities Evaluator, Nurse: 36356, RN, HFEN Health Facilities Evaluator, Nurse: 36396, RN, HFEN Health Facilities Evaluator, Nurse: 40168, RN, HFEN Total population: 90 Sample size: 21 Highest Severity and Scope: K On August 25, 2019, at 6:26 p.m. the Administrator (ADM), Director of Nursing (DON) and Infection Preventionist (a person who is an expert on practical methods of preventing and controlling the spread of infectious diseases) were verbally notified of an Immediate Jeopardy (IJ) situation. This was determined due to the potential spread of infections to other residents, staff or visitors, when isolation precautions, and cohorting of isolated residents were not implemented by the facility. The written removal plan of action was accepted on August 25, 2019 at 7:38 p.m. which included moving residents on contact isolation into single rooms, mandatory inservice of all staff on standard precautions, handwashing and proper application of personal protective equipment (PPE), LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 1 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE monitoring all staff before returning to work assignments, terminal cleaning of the rooms formerly occupied by the identified residents with 1:10 bleach solution mixtures. The IJ was removed in the presence of the ADM and the DON at the facility on August 26, 2019 at 7:57 p.m., after all the facility's plan of action was verified as implemented.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 09/24/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 2 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents (289), was provided personal privacy, when the resident's private body parts was exposed, which could be seen by roommate, and others. This failure had the potential to cause feeling of embarrassment for Resident 289. Findings: During an observation on 8/24/19 at 6:15 a.m., Resident 289 was observed on his bed with exposed private body parts. During observation, a Certified Nurse Assistant (CNA 1) went inside Resident 289's room to answer the call light. However, even though CNA 1 saw Resident 289's body parts exposed, she did not provide full privacy. During a concurrent interview regarding Resident 289's exposed private body parts, CNA 1 just looked at the resident, and then closed the curtain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 3 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 8/24/19 at 1:43 p.m., CNA 2 stated that "If a resident's private area is exposed, I will cover him right away, because that's a dignity issue... If it's my dad, I will be very mad." During an interview on 8/25/19 at 9:25 a.m., CNA 3 stated "If you see a resident exposing himself, provide them privacy right away. Put on either a gown or close the curtain due to their rights not to be exposed to their roommate, visitors or anyone who can just go in the room. That is a violation of their right to dignity." A review of the facility's policy titled "Resident's Right to Dignity and Privacy", revised 09/2017, indicated "It is the policy of the facility that each resident shall be cared for in a manner that promotes dignity, respect and individuality and provides for resident privacy. The policy further indicated the facility will protect and promote the rights of the resident...."The staff shall promote, maintain and protect resident privacy, including bodily privacy during personal care and treatment procedures."

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 09/24/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 4 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for one of 1 sampled resident, (291), the facility failed to ensure a Physician Order for Life Sustaining Treatment ([POLST] a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was completed per the resident's treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 5 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wishes. This deficient practice resulted in violation of the facility's policy to provide Resident 291's surrogate decision maker, assistance to complete, and honor the POLST upon admission. Findings: During an observation on 8/25/19 at 5:04 p.m., of a change of condition, and concurrent clinical record review for Resident 291, the POLST was left blank. During an interview on 8/25/19 5:14 p.m., with Licensed Vocational Nurse (LVN 7) stated the "Interdisciplinary Team (IDT) gathers the answers from the patient and the resident's representative and is responsible for the completion of the POLST. The physician signs it.. The admitting nurse is responsible to make sure that POLST is filled up". During an interview with the Social Services Director (SSD) on 8/25/19 at 5:15 p.m., acknowledged the responsible person for Resident 291 had not been called to verify the code status (the level of medical interventions a patient wish to have started if their heart or breathing stops) During an interview with LVN 6 on 8/25/19 at 6:49 p.m., stated "When the POLST is blank, the resident is considered a Full Code status (allows for all interventions needed to restore breathing or heart functioning). A review of Resident 291's clinical records indicated the resident was admitted on 8/19/19 and had a diagnoses of severe sepsis (a lifeFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 6 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE threatening condition caused by the body's response to an infection with acute organ failure), pneumonia (lung infection), bacteremia (presence of bacteria in the bloodstream), atrial fibrillation (irregular heartbeat that can lead to blood clots, stroke, heart failure and other), cardiac heart failure (failure of the heart to function properly), and hypertension (high blood pressure). A review of the facility's policy titled "POLST," revised 10/11, indicated, " ... The Admission or Social Service staff will review the POLST form for completeness... Nursing will add the order "Follow POLST instructions" to the resident's admitting orders for the physician to review. The primary care physician is to review this order with respect to the resident's wishes within 72 hours of admission, if possible, and sign the "Follow POLST instructions" order ...If the resident/healthcare surrogate has not completed a POLST and wishes to do so, nursing will give POLST form to the primary care physician for him/her to discuss and complete with the resident and/or healthcare surrogate..."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 09/24/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to submit an accurately coded Minimum Data Set ([MDS] a standardized assessment and care-screening tool) assessment for one of 1 sampled resident (90), who was discharge to home. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 7 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 90, who was discharged home, was coded in the MDS assessment as discharged to acute (hospital). This failure resulted in an inaccurate assessment, and data transmitted to the Centers for Medicaid and Medicare Services ([CMS] the MDS information is transmitted electronically by nursing homes to the national MDS database at CMS for data collection, assessment, and reimbursement purposes). Findings: A review of Resident 90's admission record indicated the resident was admitted to the facility on 6/20/19, with diagnoses including hypertension (high blood pressure), and diabetes (abnormal blood sugar levels). A review of the physician's discharge notes dated 7/16/19 indicated Resident 90 was discharged home due to improvement in health and the resident no longer needed services provided by facility. A review of Resident 90's clinical record in the presence of the Assistant Director of Nursing (ADON) on 8/25/19 at 7:53 a.m. indicated that resident was discharged home. A review of Resident 90's MDS assessment, dated 7/16/19, indicated the resident was discharged to acute. A review of Resident 90's Notice of Transfer/Discharge form dated 7/16/19 indicated resident was discharged home. During an interview and concurrent record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 8 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review with the MDS Registered Nurse (RN) on 8/25/19 at 11:02 a.m., confirmed Resident 90 was discharged home and not to acute, and stated MDS assessment was transmitted on 7/23/19. MDS nurse coordinator stated "Resident 90's MDS assessment discrepancy for inaccurate coding, will be modified, and MDS will be resubmitted." A review of the facility's policy and procedures revised 04/15, titled "Resident Assessment Instrument (RAI) Process" indicated the facility will utilize the RAI process for the accurate assessment of each resident's functional capacity and health status."

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 09/24/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 9 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: b. During a concurrent interview, and clinical record review for Resident 289 on 8/24/19 at 11:25 a.m. with the QA Nurse (QA), the usage of catheter and the contact precautions for Extended Spectrum Beta Lactamase in the urine (ESBL, a protein found in some strains of bacteria that can't be killed by many of the antibiotics that doctors use to treat infections) had no individualized baseline care plan developed . QA stated that "There was no baseline care plan in the chart for the use of catheter and for resident's contact precautions for his ESBL in the urine." QA also stated that the "Baseline Care Plan is done within 72 hours, to make sure there is a plan of care that is effective for the condition. If it's not there, how would everybody know that this resident is on isolation and how to prevent the spread of infection." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 10 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the Director of Staff Development / Infection Control Preventionist (DSD/IC) on 8/24/19 at 12:04 p.m., she stated that, "The importance of a baseline care plan is to know the kind of isolation they have and the set up. It is very important because it shows the staff you how to manage the isolation." DSD/IC also stated that "Part of the care plan is to prevent the spread of infection of ESBL, we do the contact precautions, we do gloves and wash hands. I am supposed to check that it is being followed." During a concurrent interview, and clinical record review with Assistant Director of Nursing (ADON) on 8/25/19 at 7:27 a.m., ADON stated "There is no baseline care plan for the catheter usage, no interventions for catheter care to protect the residents to develop recurrent urine infections and, a plan of care for contact precautions to prevent the spread of infections in the facility." On 8/24/19, the facility created a nursing care plan, related to the use of catheter and the contact precautions for ESBL in the urine for Resident #289. The facility policy titled "Baseline Care Plan", undated, indicated that "It is the policy of the facility that a baseline care pan be developed and implemented for each resident within 48 hours of admission." Based on observations, interview, and record review, the facility failed to ensure two of 21 sampled residents (67, 289), had a baseline care plan. Resident 67, did not have a baseline care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 11 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for the use of Zyprexa (used to treat mental and mood disorders), and Resident 289, did not have a baseline care plan for contact precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room), and use of indwelling catheter (a catheter that drains urine from the bladder into a bag outside of the body). These deficient practices placed the facility's care giver at risk for not knowing the specific implementations to provide to Resident 67, and 289. Findings: a. During a facility tour on 8/24/19 at 7:37 a.m., Resident 67 was observed lying on her bed and acknowledged questions by nodding the head. Certified Nurse Assistant (CNA 8) was observed attempting to assist the resident to sit up and transfer to the wheelchair, when the resident suddenly stated in a loud voice, "right there". The resident was observed with a mad facial expression before transferring herself from the bed to the wheelchair. A review of Resident 67's admission record indicated the resident was admitted on 6/7/19 with diagnoses that included not limited to cachexia (weakness and wasting of the body), muscle weakness, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizophrenia (a serious mental disorder in which people interpret reality abnormally, including hallucinations, delusions, and extremely disordered thinking and behavior FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 12 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that impairs daily functioning), and unspecified dementia (decline in memory or other thinking skills). A review of a physician's order dated 6/7/19 indicated Resident 67 was ordered Zyprexa 2.5 milligram (mg) tablet to be given by mouth (PO) at bedtime for schizophrenia, manifested by paranoid thoughts as evidenced by thinking people are touching her stuff. During an interview with the Quality Assurance Nurse (QA) on 8/25/19 at 12:50 p.m., stated was not sure the time frame for when the baseline care plans were developed "within 72 hours of admission". A concurrent review of Resident 67's medical records (chart) indicated a comprehensive care pan was dated 6/13/19. The QA nurse stated there were no other care plans for the use of Zyprexa was documented after the resident was admitted on 6/7/19. The QA nurse stated the baseline care plan was needed to implement proper interventions for the resident on a short term basis.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 09/24/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure fluid restriction was followed to one of 2 sampled residents (33), who was receiving hemodialysis (a process of purifying the blood of a person FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 13 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE whose kidneys are not working normally). This deficient practice had the potential for Resident 33 to have fluid overload (too much intake of fluids). Findings: A review of Resident 33's Admission Record indicated the resident was admitted to the facility on 7/9/19 with diagnoses including end stage renal disease and dependence of renal hemodialysis. A review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/23/19 indicated the resident had clear speech, usually able to make self understood and able to understand others, required total dependence from staff with toilet use and bathing. A review of Resident 33's Order Summary Report dated 8/12/19 indicated the following orders: - Dialysis every Tuesday, Thursday, Saturday at 5:30 a.m. - Fluid restriction of 1200 milliter (mL) per 24 hours, Dietary: Breakfast = 120 cc (cubic centimeter-unit of volume), Lunch = 120 cc, Dinner = 120 cc. The Nursing indicated: 7-3 = 280 cc, 3-11 = 280 cc, 11-7 = 280 cc, during every shift On 8/24/19 at 12:30 p.m., during a lunch dining observation, Resident 33 was eating her lunch at bedside. The resident's tray was observed with one glass of milk and one glass of juice. Resident 33 finished the glass of milk and the glass of juice. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 14 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/25/19 at 8:03 a.m., during a concurrent observation and interview, Resident 33 was eating breakfast at bedside. Resident 33's bedside table had a water pitcher containing 280 cc of water. Resident 33's breakfast tray contained 1 glass of milk and 1 cup of coffee. Resident 33 was drinking the glass of milk. Resident 33 stated she requested for a cup of coffee. On 8/25/19 at 8:07 a.m., during an interview, the Director of Staff Development (DSD) stated Resident 33's glass of milk and cup of coffee measured 240 cc. The DSD stated if the fluid restriction ordered by the physician was not followed, the resident could get more fluid than what was ordered by the attending physician. The DSD further stated Resident 33 was at risk for fluid overload because of the residents renal failure. A review of Resident 33's care plan titled "Need for Hemodialysis" revised on 7/10/19 indicated the resident was at risk for complications including fluid gain. The care plan indicated one of the interventions included "fluid as ordered."

F730 SS=E Nurse Aide Peform Review-12 hr/yr In-Service F730 CFR(s): 483.35(d)(7) 09/24/2019 §483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 15 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to conduct a performance review at least once a year for three of 5 employee files reviewed. This deficient practice had the potential for three employees not provide appropriate care to the residents, when their competencies were not checked, and or validated. Findings: On 8/26/19, at 6:33 p.m., during record review of employee files, three certified nursing assistant (CNA) employee files did not contain any documented evidence that a performance evaluation was conducted at least once a year. On 8/26/19 at 6:40 p.m., during an interview, the Director of Staff Development (DSD) stated the facility conducts a yearly performance review and documents it in a competency checklist. The DSD also stated the competency checklist was important in order to know if a CNA was providing the right care to the residents. The DSD verified and stated there were no performance reviews for the three of five employee files reviewed.

F732 SS=D Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4)

F732 09/24/2019 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 16 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to post a daily nurse staffing information at the beginning of each shift. This deficient practice resulted in staffing information not being readily available, and accessible to residents, and visitors, at any given time. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 17 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation on 8/24/19 at 5:25 a.m., the nurse staffing information posted by the charting area had a date of 8/22/19. During an interview with the Assistant Director of Nursing (ADON) on 8/26/19 at 7:55 p.m., stated the Director of Staff Development (DSD) was in charge of posting the daily nurse staffing information. During an interview with the DSD on 8/26/19 at 7:59 p.m., stated "I change it (nurse staffing information) in the morning, every day". DSD acknowledged she was aware the nurse staffing information was not done after 8/22/19. During an interview with the Administrator on 8/26/19 at 8:26 p.m., stated they did not have specific policy for posting of nurse staffing information. Administrator stated the facility followed 'All Facilities Letter' and federal requirements in regards to posting nurse staffing information. During an interview with the Director of Nursing (DON) on 8/26/19 at 8:40 p.m., stated "DSD makes a preliminary staff posting for Saturday and Sundays. If there were changes, DSD communicates it to the DON. Licensed nurses are not trained to collect the necessary data to ensure the nurse staffing is posted over the weekend. We will train the licensed for weekend on how to make it."

F756 SS=E Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 10/20/2019 §483.45(c) Drug Regimen Review. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 18 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 19 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to monitor, and document the episodes of behaviors for one of 3 sampled residents (67), with a diagnoses of paranoid (an unrealistic distrust of others or a feeling of being persecuted. extreme degrees may be a sign of mental illness) thoughts per physician's (MD) order. This deficient practice placed Resident 67 at risk for not having adequate behavior data to re-assess interventions, medications and timely treatment of escalating behaviors. Findings: During a facility tour on 8/24/19 at 7:37 a.m., Resident 67 was observed lying on her bed and acknowledged questions by nodding her head. Certified Nurse Assistant (CNA 8) was observed in the resident's room, attempting to assist resident to sit up and transfer to the wheelchair, when the resident suddenly stated in a loud voice, "right there". The resident was observed with a mad facial expression, before transferring herself from the bed to the wheelchair. A review of Resident 67's admission record indicated the resident was admitted on 6/7/19 with diagnoses that included not limited to cachexia (weakness and wasting of the body), muscle weakness, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizophrenia (a serious mental disorder in which people interpret reality abnormally, including hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning), and unspecified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 20 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dementia (decline in memory or other thinking skills). A review of a physician order dated 6/7/19 indicated to administer Zyprexa 2.5 milligram (mg) tablet, by mouth (PO), at bedtime for schizophrenia to Resident 67, for behavior manifested by paranoid thoughts as evidenced by thinking people are touching her stuff. A review of a physician's order for Resident 67 dated 6/7/19 indicated to monitor behavior episodes of paranoid thoughts as evidenced by thinking people are touching her stuff every shift (q shift), and tally by hashmarks for (Zyprexa). The order indicated to see behavior flow sheet. A review of the Behavior/ Intervention Monthly Flow Record for Resident 67 dated 8/2019 indicated the following dates had incomplete, or no documentation for episodes of behavior, interventions and outcomes: Day shift : 8/1/19 through 8/23/19 Evening shift : 8/1/19 through 8/23/19 Night shift : 8/2/19 through 8/4/19; 8/7/19; 8/9/19 through 8/11/19; 8/13/19 through 8/23/19 During an interview with the Quality Assurance (QA) nurse on 8/25/19 at 12:33 p.m., stated her responsibilities included assisting the facility psychiatrist when he did his resident visits, to review the pharmacist medication record review (MRR) and to review the tallying of the hashmarks for monthly behavior monitoring for the residents. The QA nurse stated with behavior monitoring for every tally mark, there should be an intervention which included redirecting the resident or 1:1 care or of they charted on the nurse's notes. The QA nurse stated blank spaces on the behavior monitoring flow sheet meant it was not done and had to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 21 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE filled out per the MD order. The QA nurse stated documenting attempted interventions was necessary to improve the resident's quality of life. The QA nurse stated the monthly hash mark was used by the psychiatrist to reevaluate ongoing treatment and possible gradual dose reductions (GDR), depending on the number of behavior episodes whether the resident had an increase or decrease in episodes. The QA nurse stated because of the missing documentation, she was unable to tell whether there was an increase or decrease in Resident 67's behavior in the month of August 2019. A review of the facility's policy last revised 8/15 titled "Psychotherapeutic Drug Treatment" indicated the facility staff will document episodes of behavior, the impact of medication on behavior, and the presence or absence of side effects.

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 09/24/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 22 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a discontinued medication for Lexapro (used to treat depression and anxiety) was carried out, Ambien (used to induce sleep) given as needed (PRN) was re-evaluated after 14 days, for one of 3 sampled residents (74), and the facility's policy included the regulatory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 23 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE guidelines relating to 14 day limit for the use of "as needed" psychotropic medications. These deficient practices resulted in Resident 74 receiving two anti-depressant medications at the same time, not having a policy that included the regulatory guidelines relating to 14 day limit for the use of as needed psychotropic medications, and not re-evaluated for continued use of Ambien after 14 days, could lead to potential adverse side effects. Findings: a. During a facility tour on 8/24/19 at 6:34 a.m., Resident 74 was observed sleeping in his room. On the same day at 7:56 a.m. , the resident was observed with eyes closed while breakfast tray was on his over bed table. During an interview with Resident 74 on 8/26/19 at 4:20 p.m., stated he was on hemodialysis (a process of purifying the blood when the kidneys are not working normally) for the rest of his life, which made him feel very depressed. The resident stated he did not feel like doing anything after he came back to the facility from hemodialysis treatment center. Resident 67 stated he also had problems sleeping. The resident also state he had lost weight and was eating bean burritos all week because he did not care for the food the facility served from their menu. A review of Resident 74's admission record indicated the resident was admitted on 11/6/18 and re-admitted on 7/11/19 with diagnoses that included not limited to end stage renal disease (kidney failure), dependence on renal hemodialysis, diabetes (abnormal blood sugar levels), and blindness of the left eye. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 24 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 74's History and Physical examination done by the physician dated 7/12/19 indicated the resident had the capacity to understand and make decisions. A review of an Order Note dated 8/14/19 indicated Resident 74 was seen by the psychiatric Nurse Practitioner (NP 1) with a new order to discontinue (DC) Lexapro and change to a more appropriate antidepressant, such as Remeron to cover depression manifested by poor appetite. The Order Note further indicated informed consent was obtained by the MD and the order was noted and carried out. A review of Resident 74's MD orders indicated no order to discontinue the use of Lexapro. An order dated 8/14/19 indicated an added Remeron 15 milligram (mg) , 1 tablet by mouth (PO) at bedtime for depression manifested by poor appetite. A review of Resident 74's medication administration records (MARs) dated 8/1/19 to 8/31/19 indicated the resident received Lexapro 10 mg 1 tablet by mouth in the morning for depression manifested by verbalization on sadness due to current health condition from 8/14/19 to 8/24/19. The MARs also indicated Remeron 15 mg 1 tablet by mouth at bedtime for depression manifested by poor appetite was given from 8/15//19 to 8/25/19. During an interview and record review with the Quality Assurance (QA) nurse on 8/26/19 at 4:28 p.m., stated all nurses were responsible for carrying out MD orders, however the NP order dated 8/14/19 was missed and Resident 74 was on two anti depressants for a total of 10 days. The QA nurse state the dual anti depressants side effects included increased FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 25 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE drowsiness. A review of the facility's policy last revised on 8/16 titled "Physician Orders" indicated the charge nurse or Director of Nursing (DON) shall place the order for all prescribed medications. Drugs and biological orders must be recorded on the Physician's Order sheet in the resident's clinical record. b. During an interview with the Quality Assurance (QA) nurse on 8/25/19 at 12:33 p.m., stated her responsibilities included assisting the facility psychiatrist when he did his resident visits and to review the pharmacist medication record review (MRR). During an interview and record review with the QA nurse on 8/26/19 on 4:28 p.m., stated she was not aware Resident 74 was prescribed Valium by his primary care physician and verified a concurrent record review indicated the resident had an order for Valium 5 mg, 1 tablet by mouth as needed for insomnia before sleep (QHS). However, QA nurse acknowledged there was no 14-day stop date on the order for Valium 5 mg for Resident 74. The QA nurse stated Valium has a sedative (sleepiness) effect. The QA nurse stated Resident 74 requested Ambien (sleeping medication) from the psychiatrist. During a concurrent review of MD orders and interview for Resident 74 indicated to administer Ambien 5 mg 1 tablet by mouth as needed for insomnia manifested by inability to sleep for 30 days give at bedtime as needed (PRN) dated 8/4/19. During an interview QA nurse stated when a psychotrophic medication is given as needed (PRN) basis, the initial order had to have a duration of 14 days, then the resident needed to be see by his psychiatrist to justify the use of the medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 26 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the medication administration records (MARs) dated 8/1/19 to 8/31/19 for Resident 74 indicated Ambien was given on 8/5, 8/6, 8/9, 8/10, 8/11/, 8/12, 8/14, 8/15, 8/16, 8/17, 8/18, 8/21, 8/22/, 8/23, 8/24 and 8/25/19. A review of the facility's policy last revised 8/15 titled "Psychotherapeutic Drug Treatment" indicated psychotherapeutic drugs included antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics and other drugs that may affect behavior. However, the policy did not include the guidelines relating to the use of "as needed" psychotrophics medications 14 day limit on its use.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 09/24/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 27 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure: a. One of three medication carts was locked. b. Indicate open dates for multiple use high and low glucose machine control solutions and multiple dose Humulin R (medication to control abnormal blood glucose). These deficient practices had the potential for inaccurate blood glucose results and access to medication by unauthorized person or resident. Findings: a. During medication administration observation on 8/24/19 at 5:43 a.m., licensed vocational nurse (LVN 3) was observed dispensing the following medications for Resident 43. 1. Famotidine (antacid) 20 milligrams (mg) 2. Glipizide (medication for abnormal blood glucose) 3. Levothyroxine 50 micrograms (mcg) 4. Gemfibrozil 600 mg Concurrently, LVN 3 entered Resident 43's room, left the medication bubble packs on top of the medication cart, and did not lock the medication cart. LVN 3 closed the privacy curtains to administer Resident 43's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 28 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications, making the medications not visible. b. During an inspection of medication cart three (3) on 8/24/19 at 4:45 p.m., a multiple dose vial of opened Humulin R was observed with no open date, and two opened bottles of "Assure Dose High and Low Control Solutions" on 9/2020, had no open dates. Concurrently, LVN 5 stated "I don't know when to discard after opening the bottles." Concurrently, a review of the manufacturer's insert for "Assure Dose High and Low Control Solutions," indicated to "use within 90 days of opening and write on bottle date opened." During an interview on 8/26/19 at 8:19 p.m., the director of nursing (DON) stated the medication cart must be locked before the licensed nurse walked away, during the administration of medications to Resident 43, to prevent accidental ingestion or diversion by staff and or residents, which could result in undesirable adverse drug effects. A review of the facility's policy titled "Medication Labels" dated 4/2014, indicated medications are labeled in accordance with facility requirements and, State and Federal laws.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 09/24/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 29 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: Check temperature for two chicken patties and three beef patties prior to serving them to the residents, Ensure a scooper was not left inside a ground coffee bin, and Personal cell phone, and keys were stored away from residents' food preparation area. These deficient practices had the potential for food contamination and spread of infection to the residents. Findings: a. During the initial kitchen tour on 8/24/19 at 5:19 a.m., Cook 1 acknowledged the following: 1. A scooper was left inside a ground coffee bin. 2. A personal cell phone, bread in a clear plastic bag, bunch of keys, were stored on a tray that had several plastic food covers, food thermometers, and a box of single use alcohol wipes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 30 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. During food tray line observation on 8/24/19 at 12:09 p.m., dietary aide (DA 2) wore clean gloves, received a food request slip from a staff, before spreading mayonnaise and thousand dressing on four pieces of buns, without changing the gloves. DA 2 did not change gloves or perform hand hygiene after touching the food request slip. Concurrently, DA 2 was observed removing two chicken and three beef patties from the grill, put them on the buns with mayo and thousand island dressing before placing them in the food cart to be served to the residents. DA 2 did not take the temperatures of the chicken and beef patties to ensure they were at the correct serving temperatures. During an interview on 8/24/19 at 1:09 p.m., DA 3 stated "I prepare coffee. I remember that I left that coffee scooper inside the coffee bin. I should have placed it inside a plastic bag to keep the coffee clean and free of contamination." During an interview on 8/24/19 at 1:13 p.m., DA 2 stated "before I serve any kind of food, I must check the temperature to ensure the food is at the correct temperature to prevent bacteria growth. The residents can get sick and have diarrhea." DA 2 stated she checked if chicken and beef patties were thoroughly cooked by "cutting the middle to see if it is cooked." DA 2 acknowledged she did not check the temperature of the beef patties and chicken, nor change her contaminated gloves after touching food request slip, and potentially undercooked meat. During an interview on 8/24/19 at 1:37 p.m., the dietary supervisor (DS) stated any surface used to prepare food and beverages, or store food containers/supplies was considered a food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 31 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE preparation area. The DS stated "we disposed the contaminated coffee and washed the coffee bin." A review of the facility's policy titled "Food Preparation" dated 2012, indicated prepared hot food would be stored at temperature greater than 140 degrees until served.

F880 SS=J Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 09/24/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 32 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: c. A review of the admission record, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 33 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 43 was admitted to the facility on 5/31/19 with diagnoses not limited to septicemia (severe infection). A review of the MDS dated 7/19/19, indicated Resident 43 had moderate cognitive impairment. During medication administration observation on 08/24/19 at 5:43 a.m., licensed vocational nurse (LVN 3) was observed wash hands, wear clean gloves and used the same gloves to close Resident 43's privacy curtains. LVN 3 was observed touch Resident 43's finger, stuck and obtain a blood sample to check the resident's blood sugar. However, LVN 3 did not change her gloves or perform hand hygiene. d. A review of the admission record, indicated Resident 84 was admitted to the facility on 7/14/19, with diagnoses not limited to sepsis (severe infection). A review of the MDS dated 7/21/19, indicated Resident 84 had no cognitive impairment. A review of a history and physical (H&P) dated 7/15/19, indicated Resident 84 had the capacity to understand and make decisions. During medication administration on 8/24/19 at 8:09 a.m., LVN 4 was observed wash hands,wear clean gloves, closed privacy curtains, and checked Resident 84's blood pressure wearing the same gloves. LVN 4 did not change gloves or perform hand hygiene. During an interview on 8/25/19 at 11:58 a.m., LVN 4 stated "l should not touch potentially contaminated surfaces with clean gloves (bedside table, privacy curtains) then provide care to residents because of spread of infection. I should have removed my gloves FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 34 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and washed my hands." A review of the facility's policy titled "Infection Control-Enhanced Standard Precautions" dated 3/16, indicated to change gloves during the care of a resident to prevent cross contamination Based on observation, interview, and record review, the facility failed to implement their system of infection prevention and control program for six of 6 sampled residents (49, 239, 4, 45, 289, 63) when: a. Certified Nursing Assistant (CNA) 5 did not wear personal protective equipment ([PPE] equipment designed to protect the wearer's body from infection that includes gowns, gloves, mask or goggles) upon entering an contact isolation (a form of isolation in which anyone entering the patient's room and having direct contact with the resident or environment wears PPE) rooms shared by Resident 49, 239, and 4. In addition to, CNA 5 did not perform hand washing after providing assistance to Resident 49. b. Resident 45's urinary drainage bag was observed touching the floor after CNA 5 provided activities of daily living (ADL-daily activities that a resident perform such as feeding, bathing, dressing, grooming) care. c. Licensed Vocational Nurse (LVN) 3 was observed not wearing PPE while inside the contact isolation room shared by Residents 289 and 63. d. Housekeeping Staff (HK) 2 did not wear PPE upon entering the contact isolation room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 35 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE shared by Residents 49, 239 and 4. e. Resident 4 was fixing Resident 239's bed,who is on contact isolation, without wearing proper PPE. f. CNA 7 did not perform hand washing and did not wear PPE upon entering a contact isolation room shared by Residents 49, 239 and 4. g. Physical Therapy Assistant (PTA) 1 did not wear PPE upon entering the isolation room of Resident 45 and did not perform hand washing prior to providing therapy to the resident. h. The facility did not follow its policy and procedure by placing residents with known infection, which includes cohorting (grouping residents with common infection) residents and assessing possible roommates of residents on contact isolation, who have low risk of acquiring infections. These deficient practices had the potential to result in the spread of infections to other residents, staff, and visitors in the facility. Due to these deficient practices, the Administrator (ADM), Director of Nursing and Infection Preventionist (a person who is an expert on practical methods of preventing and controlling the spread of infectious diseases) were verbally notified of an Immediate Jeopardy (IJ) situation, on August 25, 2019, at 6:26 p.m. This was determined due to the potential spread of infections to other residents, staff or visitors when contact isolation precautions and cohorting of isolated residents were not implemented by the facility. The written removal plan was accepted on August 25, 2019, at 7:38 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 36 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The IJ was removed in the presence of the ADM and the DON at the facility on August 26, 2019, at 7:57 p.m., after the facility's plan of action was verified to have been implemented. Findings: a. A review of Resident 49's Admission Record indicated the resident was admitted to the facility on 4/16/17 with diagnoses including chronic obstructive pulmonary disease (COPD - a type of lung disease characterized by longterm breathing problems associated with productive cough) and dementia (brain disease that cause a long-term and gradual decrease in the ability to think and remember affecting a person's daily functioning). A review of Resident 49's History and Physical dated 7/9/19 indicated the resident does not have the capacity to understand and make decisions. On 8/24/19, at 5:43 a.m., during the initial tour of the facility, Certified Nursing Assistant (CNA) 5 entered the room shared by Residents 49, 239 and 4 without wearing PPE. CNA 5 entered the bathroom and gave a paper towel to Resident 49. CNA 5 was observed touching the environmental surfaces in the shared room including the bathroom door knob, the privacy curtain, and Resident 49's bedside table. CNA 5 left the room after giving the paper towel without washing her hands. Resident 49 called for help a second time and CNA 5 entered the room again without wearing PPE. CNA 5 picked up a roll of toilet paper that fell under the bed and gave it to Resident 49. The resident was coughing and used the roll of toilet paper to cover her mouth while coughing. CNA 5 did not perform hand washing before leaving the room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 37 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/24/19, at 5:46 a.m., during an interview, CNA 5 stated Resident 49 asked for paper towels and toilet paper. CNA 5 stated the shared room of Residents 49, 239 and 4 has a sign posted by the door indicating, "Contact isolation." CNA 5 stated the isolation is for Resident 239, but did not know what type of isolation. CNA 5 further stated she only wears PPE in the room if she is taking care of the Resident 239 who is on isolation. CNA 5 further stated she did not perform hand washing before leaving the isolation room. On 8/24/19, at 6:52 a.m., during an interview, Registered Nurse (RN) 3 stated Resident 239 was admitted to the facility on 8/23/19. RN 3 stated he did the admission assessment. RN 3 further stated Resident 239 is in contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA-drug resistant organism that can cause wound infections and infections of invasive devices such as catheters) of the nares and is receiving antibiotic (medicine used to treat infections) treatment for it. b. A review of Resident 45's Admission Record indicated the resident was readmitted to the facility on 8/21/19 with diagnoses including urinary tract infection (infection in any part of the urinary passageway), dementia (brain disease that cause a long-term and gradual decrease in the ability to think and remember affecting a person's daily functioning) and neuromuscular dysfunction of the bladder (causes difficulty or full inability to pass urine without use of tube to drain urine). A review of Resident 49's History and Physical dated 8/21/19 indicated the resident has fluctuating capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 38 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 49's "Order Summary Report" dated 8/21/19 indicated the following orders: - Connect Foley catheter (an indwelling flexible tube inserted into the urinary tract to drain urine) 18FR (French - size of catheter) to bedside drainage bag (a device that collects the drained urine). - Foley catheter care daily and as needed every shift. A review of Resident 45's Progress Notes dated 8/23/19 indicated the resident is on isolation precautions and is on Meropenem (antibiotic) every 8 hours for ESBL (Extended Spectrum Beta Lactamase-a protein produced by a strain of bacteria that causes medications to be ineffective) of the urine. On 8/24/19, at 6:21 a.m., Resident 45's indwelling catheter drainage bag was observed touching the floor. Resident 45's bed was in a low position. On 8/24/19, at 6:27 a.m., during an interview, CNA 5 stated she placed Resident 45's bed to the lowest position after changing the resident's adult briefs. CNA 5 verified and stated Resident 45's indwelling catheter drainage bag was touching the floor. CNA 5 further stated the catheter drainage bag should not touch the floor to prevent contamination (the presence of undesirable organisms that may cause infection). On 8/24/19, at 12:54 p.m., during an interview, the Quality Assurance (QA) Nurse stated the indwelling catheter drainage bag should not touch the floor to prevent contamination. A review of the facility's policy and procedure titled, "Indwelling Catheter," dated 5/14, indicated, "...Urinary catheters are cared for by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 39 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE all licensed nursing personnel...Caution should be taken not to allow the ends of the spout to touch anything that will contaminate it..." c. A review of Resident 289's Admission Record indicated the resident was admitted to the facility on 8/12/19 with diagnoses including malignant neoplasm of large intestine (abnormal growth of cells that have the ability to invade or spread to other parts of the body), s/p (status post-after) colostomy (opening of large intestine to abdominal wall which serves as passageway of stool) and diabetes mellitus (chronic elevated blood sugar). A review of Resident 289's Minimum Data Set (MDS - a comprehensive assessment and care planning tool) dated 8/16/19 indicated the resident's brief interview of mental status (BIMS- screens for cognitive impairment) score was 15 [a score of 13-15 indicates intact (cognition-process of acquiring knowledge and understanding through thought, experience, and the senses)], required extensive assistance with one-person physical assist with bed mobility, transfer, toilet use, personal hygiene and bathing. A review of Resident 289's "Physician Order" dated 8/19/19 indicated the following orders: - Contact precautions for Extended Spectrum Beta Lactamase (ESBL, a protein produced by a strain of bacteria that causes drug resistance) in the urine until further orders. - Merrem (antibiotic) 500 milligrams (mg) intravenously (IV, in the vein) one time a day for urinary tract infection until 8/26/19. On 8/24/19, at 7:10 a.m., during an observation, LVN 3 was inside Resident 289's room while talking to the resident. LVN 3 was holding onto the privacy curtain with her right hand without any PPE (gowns and gloves). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 40 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 289's room was observed with a contact isolation sign (measures intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment) placed on top of an isolation cart (set of drawers containing PPE). Resident 289's roommate, Resident 63, was observed in his bed. A review of Resident 63's Admission Record indicated the resident was admitted to the facility on 7/31/19 with diagnoses including sepsis, acute cholelithiasis (inflammation of gallbladder due to stones), s/p (status post) open cholecystectomy (surgical removal of gallbladder) and left femur fracture (broken thigh bone) s/p surgery. A review of Resident 63's Physician Progress Notes dated 8/24/19 indicated the resident had a healing left hip surgical scar and an abdominal surgical wound. On 8/24/19, at 12:04 p.m., during an interview, the Director of Staff Development (DSD) stated, "To prevent the spread of infection of ESBL, we do the contact precautions, we do (wear) gloves and wash hands. I am supposed to check that it is being followed." The DSD further stated, "You wear your PPE before you enter an isolation room. You are supposed to wear gloves when you hold the curtain. The policy is before we enter an isolation room and when your body is inside, you are supposed to wear your PPE to prevent the spread of infections." On 8/25/19, at 7:04 a.m., during an interview, Registered Nurse (RN) 2 stated, "We wear PPE when we do patient care. We wear PPE before we go inside. It is not okay not to wear PPE even if you just say hi to the resident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 41 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/25/19, at 9:24 a.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, "When going to the isolation room, wear gown, gloves and all the PPE needed depending on what kind of isolation there is. When you leave the room, remove your PPE first and then you wash your hands. It is not okay to go inside the isolation room even if you don't touch the patient because it is an infected room." On 8/25/19, at 4:56 p.m., during an interview, Resident 289 stated staff sometimes do not wear the yellow gown when they come into the room to provide care. On 8/26/19, at 3:20 p.m., during an interview, the Assistant Director of Nursing (ADON) stated, "The Admission coordinator is responsible for room assignments for new admissions. They also make the bed availability and they decide where to put the residents. I am not sure if they are aware of the cohorting." On 8/26/19, at 3:46 p.m., during a concurrent interview and record review, the ADON stated Resident 63 is vulnerable for development of infections due to his compromised condition. The ADON also stated Resident 63 is exposed to Resident 289's ESBL infection because they share a room. d. On 8/24/19, at 10:57 a.m., during an observation, Housekeeping Staff (HK) 2 was observed entering the room shared by Residents 49, 239 and 4. HK 2 did not wear PPE prior to entering the contact isolation room. On 8/24/19, at 11:56 a.m., during an interview, Licensed Vocational Nurse (LVN) 5 stated if a shared room is on contact isolation, all staff must wear PPE before entering the room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 42 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE e-f. A review of Resident 239's admission record indicated the resident was admitted to the facility on 8/23/19 with diagnoses including difficulty in walking, muscle weakness, s/p (status post) knee replacement surgery and Methicillin Resistant Staphylococcus Aureus infection (MRSA- drug resistant organism that can cause wound infections and infections of invasive devices such as catheters). A review of Resident 239's Order Summary Report dated 8/24/19, indicated an order for Mupurocin ointment (antibacterial) 2 %, apply to nares (nostril) topically 2 times a day for 5 days for MRSA. A review of Resident 4's Admission record indicated the resident was admitted to the facility on 7/16/19 with diagnoses including diabetes mellitus (chronic elevated blood sugar) and hypertension (chronic elevated blood pressure). A review of Resident 4's "History and Physical" dated 6/18/19 indicated the resident had a history of C. diff (clostridium difficile - a type of organism causing infectious diarrhea), history of UTI (urinary tract infection), and had the capacity to understand and make decisions. On 8/24/19, at 11:25 A.M., during an interview, Resident 239 stated she had a knee surgery a couple of days ago. Resident 239 stated she is not sure why she is on contact isolation. Resident 239 stated the hospital staff told her, "I have a bug or something." Resident 239 further stated she is currently getting treatment for it. A review of Resident 239's "Progress Notes" dated 8/25/19, at 6:30 a.m., indicated, "...Resident is a new admit. Resident is s/p FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 43 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (status post) right knee replacement and is on isolation precautions for MRSA of the nares..." On 8/25/19, at 9:04 a.m., during a concurrent observation and interview with RN 1, Resident 4 was observed fixing the bed of Resident 239. Resident 4 was not wearing any PPE while fixing the linen and blanket of Resident 239's bed. CNA 7 entered the shared isolation room of Residents 49, 239 and 4 without wearing any PPE. CNA 7 touched Resident 239 on the right shoulder and wheeled Resident 239 out of the room. CNA 7 did not perform hand washing before entering and after leaving the room. RN 1 stated every time anybody enters an isolation room, they have to wash hands and wear the appropriate PPE. RN 1 stated Resident 239 has MRSA of the nares and is currently receiving antibiotic treatment for it. RN 1 also stated MRSA is spread via contact (spread by direct or indirect contact with the resident or the resident's environment) from possible sources which includes beds, linens, gowns and hands. g. On 8/25/19, at 3:05 p.m., during a concurrent observation and interview, Physical Therapy Assistant (PTA) 1 entered Resident 45's room without wearing PPE. PTA 1 did not perform hand washing, touched the privacy curtains in Resident 45's room. PTA 1 stated he did not see the isolation sign posted by the door when he entered Resident 45's room. A sign indicating, "Stop" was observed by the door of Resident 45's room and a sign indicating, "Contact Isolation" was observed on top of the isolation cart located outside the room by the door. On 8/25/19, at 3:15 p.m., during an interview, RN 1 stated he provided in-services only to the nursing department on 8/24/19 when staff have been observed to enter isolation rooms without wearing PPE. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 44 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE h. On 8/25/19, at 4:44 p.m., during an interview, the Director of Staff Development (DSD) stated she is also the Infection Control Nurse. The DSD also stated she is not the one responsible for room placement of residents being admitted with isolation precautions. The DSD was unable to give an answer when asked how residents are placed in the room together if they have an infection. On 8/25/19, at 4:55 p.m., during an interview, the Director of Nursing (DON) stated the facility did not follow its policy and procedure in cohorting Residents 45 and 289. The DON stated Residents 45 and 289 have the same microorganisms causing an infection. The DON also stated the facility did not follow its policy and procedure in placing Resident 239, who is on contact isolation for MRSA, in a room with residents who are at low risk for acquisition (chances of getting the infection). The DON also stated Residents 49 and 4 have high risk of acquiring the MRSA because all of the residents use the same toilet. On 8/26/19, at 5:48 p.m., during an interview, the Admissions Coordinator (AC) stated she coordinates with a registered nurse on duty for room placement. The AC further stated it was RN 3 who determined the placement for Resident 239. A review of the facility's policy and procedure titled, "Infection Control," dated 5/2018, indicated, "...The facility maintains written standards, policies and procedures for the infection control program, which includes...When and how isolation should be used for a resident, including the type and duration of the isolation, depending upon the infectious agent or organism involved...The facility has designated the Director of Staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 45 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Development as the Infection Preventionist (IP) to oversee the infection control program...The IP utilizes the facility policies to address standard and transmission-based precautions..." A review of the facility's policy and procedure titled, "Infection Control-Enhanced Standard Precautions," dated 3/2017, indicated, "...When single resident rooms are not available, residents with the same MDRO [multi-drug resistant organism (an organism that is hard to treat with antibiotics)]will be cohorted in the same room...When cohorting residents is not possible, MDRO residents will be placed in rooms with residents who are at low risk for acquisition...Use contact precautions for specified patients known or suspected to be infected or colonized with epidemiologically (dealing with incidence, distribution and control of a disease) important microorganisms that can be transmitted by direct with the patient...Wash hands before and after utilizing gloves or coming in direct contact with resident/environment for 15-30 seconds...Gowns are worn to prevent the transfer of infectious agents from the resident's skin, clothing, bedding and environmental surfaces to the HCP (health care personnel) bare skin and clothing..."

F921 SS=B Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 09/24/2019 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 46 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide an environment that was homelike, and free of clutter, for one of 1 sampled residents (289). This failure had the potential to cause accidents and injuries to Resident 289. Findings: On 8/24/19 at 6:15 a.m., the following was observed in Resident 289's room: The hand sanitizer dispenser by the entrance door was not working. The room was cluttered. The bedside commode had a basin and a box sitting on top of it. There was a disinfectant wipes beside the bag of grapes on the bedside cabinet. The bathroom sink had a black colored residue and white colored deposits. On 8/24/19 at 7:33 a.m., Registered Nurse (RN 3) confirmed the hand sanitizer dispenser next to Resident 289's room was not working. During an interview with the Director of Staff Development on 8/24/19 at 12:38 p.m., stated Resident 289's grapes should not be stored close to the disinfectant wipes. During an interview with Certified Nurse Assistant (CNA 2) 8/24/19 at 1:43 p.m., stated "When I came in this morning, the bedside was too messy. There was coffee cup. There was a trash where the TV was. There were grapes ... If there are equipment in the facility that is not working or that needs repair, we let the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 47 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintenance know by writing it down in the maintenance log book. Maintenance personnel checks the log book every day." A review of the maintenance log book from 07/2018 to present time did not indicate Resident 289's sink black colored residue and white colored deposits was written and reported by a staff. During an interview with the Housekeeping Supervisor (HKS) on 8/24/19 at 2:19 p.m., confirmed Resident 289's sink faucet had a black colored residue and white colored deposits and the hand sanitizer dispenser next to the room was not working. HKS stated that, "I'm not sure if this was reported. I will tell the maintenance to have it replaced." HKS also stated, housekeeping's responsibility is to report to the HKS or the maintenance Supervisor anything that they see, that needs to be repaired and changed." During an interview with CNA 3 on 8/25/19 at 9:29 a.m., stated "If there are broken equipment, we tag them and put it where the broken equipments are. We log it in the maintenance log with the room number then we double check to make sure that is being fixed..." CNA 3 also stated "it is not okay for a food to be close to any chemicals. The patient could take in some of the chemicals exposed to the food. The resident could have food poisoning...If we have the chance to organize the bedside and help in cleaning the closet and everything at the bedside, we do it. It is for resident's safety. So it will be like a homelike environment..." During an interview with the Maintenance Supervisor on 8/25/19 at 10:19 a.m., stated "There is a maintenance log book at each nurse's station and whatever needs to be fixed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 48 of 49 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555348 (X3) DATE SURVEY COMPLETED 08/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANADA POST ACUTE 3565 E Imperial Hwy Lynwood, CA 90262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or replaced, they write it down and I check on it." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BH9T11 Facility ID: CA940000076 If continuation sheet 49 of 49