Other·June 16, 2017

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: Surveyor ID#: 36535 Surveyor ID#: 36396 Surveyor ID#: 36205 Total Resident Population: 91 Total Resident Sample: 19 CA00536375 = Substantiated (F-225) Highest Scope and Severity: F

F205 SS=D NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR CFR(s): 483.15(d)(1)(i)-(iv)(2)

F205 06/07/2017 (d) Notice of bed-hold policy and return(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing 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: THR311 Facility ID: CA950000039 If continuation sheet 1 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility’s policies regarding bedhold periods, which must be consistent with paragraph (c)(5) of this section, permitting a resident to return; and (iv) The information specified in paragraph (c) (5) of this section. (2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide a written bed-hold notification for one of 19 sampled residents (Resident 16). This deficient practice had the potential for the resident and/or the legal representative not to be fully aware of the availability and duration of the bed-hold at the time of transfer. Findings: A review of the Admission face sheet indicated Resident 16 was admitted to the facility on 2/12/17, with diagnoses of pulmonary fibrosis (condition in which the tissue deep in your lungs becomes scarred over time) and weakness. Resident 16 was transferred to the acute general hospital on 2/19/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 2 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 facility form titled, "Discharge Summary," indicated Resident 16 was transferred to the acute care hospital on 2/19/17 for respiratory distress. On 5/21/17 at 10:15 a.m., during a concurrent record review and interview with the Medical Records Director (MR Director), stated there was no form or documentation for Bed-Hold Notification in Resident 16's clinical record. The MR Director stated the admission packet which contained the Bed-Hold Notification form was not in Resident 16's clinical record. This was the reason why it was not completed by the licensed nurse. A review of the facility's form titled, "Bed-Hold Acknowledgement," indicated the form was to be completed upon discharge. The form also indicated that the resident or legal representative has been notified of the option of having the bed held for a maximum of seven days after transfer to an acute hospital. Further review of the form, indicated the resident/legal representative had a choice to not hold a bed or hold bed for ___ (blank to indicate desire number of days for hold) days. A review of the facility's policy and procedure titled, "Transfer or Discharge Documentation," dated 8/2014, indicated that when a resident is transferred or discharged, a documentation concerning all transfers must include that an appropriate notice was provided to the resident and/or representative.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 06/06/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 3 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 4 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to immediately report (within 24 hours) an injury of unknown source to the State survey and certification agency for 1 of 19 sampled residents (Resident 11). This deficient practice had the potential to put Resident 11's safety at risk. Findings: A review of Resident 11's profile face sheet indicated Resident 11 was admitted to the facility on 1/9/2014, with diagnoses that included cerebral infarction (brain injury resulting from decreased blood supply and oxygen), hypertension (chronic elevated blood pressure), Alzheimer's disease (brain disorder that is characterized by long term and gradual decrease in the ability to think and remember) and hyperlipidemia (elevated fats in the blood). A review of Resident 11's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool dated 4/13/17, indicated Resident 11 had a brief interview for mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 5 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 (BIMS- screens for cognitive impairment) score of 3 (a score of 0-7 indicates severely impaired cognition), required extensive assistance with 2 person assist for transfer and toilet use, had no impairment in range of motion for bilateral upper extremity (shoulder, elbow, wrist, hand). A review of Resident 11"s "Licensed Nurses Progress Notes" dated 5/12/17, indicated Resident 11 complained of left shoulder pain. Indentation was noted on the left anterior shoulder which was tender (painful) to touch, and the resident was unable to move the left upper extremity. The attending physician was notified and ordered a Stat (immediate) x-ray (photo image to check for abnormalities of bone and soft tissue) of the left shoulder. A review of Resident 11's "X-Ray of left shoulder" dated 5/12/17, indicated Resident 11 had an anterior/inferior left shoulder dislocation. A review of Resident 11's "Physician Telephone Order Sheet" dated 5/12/17, indicated to transfer Resident 11 to the General Acute Care Hospital (GACH) for evaluation of the left shoulder dislocation. A review of Resident 11's GACH notes titled, "Emergency Documentation" dated 5/12/17, indicated Resident 11 was transferred to GACH due to left shoulder pain. Resident 11 underwent procedural sedation (a technique of administering substance that induces sedation that allows the patient to tolerate unpleasant procedures) and reduction (a procedure to restore dislocation to correct alignment) of the left shoulder dislocation. During an interview with Licensed Vocational Nurse (LVN) 3 on 5/19/17 at 7:00 p.m., LVN 3 stated that Resident 11 did not have any fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 6 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 incident. LVN 3 also stated that the left shoulder dislocation is an injury. LVN 3 also stated that Resident 11 is confused and could not tell how the shoulder got dislocated. LVN 3 also stated that nobody from the facility knew how Resident 11's left shoulder got dislocated. LVN 3 also stated that this should have been reported to the state. During an interview with the Director of Nursing (DON) on 5/19/17 at 7:19 p.m., the DON stated that she did a thorough investigation of Resident 11' left shoulder dislocation incident. The DON also stated that the left shoulder dislocation is an injury, and that nobody knew how Resident 11's shoulder was dislocated. The DON also stated that Resident 11 had osteoporosis and stiff shoulders, and the left shoulder dislocation could have been due to osteoporosis and stiff shoulders. The DON also stated that she did not report the injury of unknown source to state licensing and certification agency. The DON further stated that she will report Resident 11's injury of unknown source to the State now. During an interview with the Administrator on 5/20/17 at 10:00 a.m., the Administrator stated she did not file a report about Resident 11"s injury of unknown source, because she was focused on the result of the x-ray showing no fracture. A Review of an undated facility's policy and procedure titled, "Abuse Investigations" indicated all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. A review of an undated facility policy and procedure titled, "Reporting Abuse to Facility Management" indicated that when an alleged FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 7 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility's administrator, or his/her designee, will notify the following persons or agencies of such incident within twenty-four (24) hours as deemed appropriate based on the initial investigation: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; g. The Facility Medical Director.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 05/22/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 8 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to: a. Ensure one of five new employees had a background check completed prior to employment. This has the potential for the facility to not be able to identify the employee's criminal background before providing care to the resident. b. Ensure that two of nine employees knew that incidents of abuse must be reported to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 9 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 State Licensing and Certification office. This deficient practice had the potential for staff not to report abuse if the need arises. Findings: a. On 5/20/17 at 3:00 p.m., during a review of five new employee files, the file for the registered nurse (RN) with the hire date 5/8/17, did not have a live scan results prior to employment. On 5/20/17 at 3:15 p.m., during an interview, the director of staff development (DSD) stated the facility's policy and procedure was to screen potential employees for a history of abuse, neglect, or mistreatment of residents and potential employees are fingerprinted through live scan. The DSD stated that the RN's live scan result was not on file. The DSD stated that the results of the live scan should be checked prior to the employment of a RN. On 5/20/17 at 4:10 p.m., during an interview, the administrator stated the facility has not received the RN's live scan results and should not have allowed the RN to start prior to receiving the live scan results. A review of the facility's undated policy and procedure titled, "Key Components to Prevent Abuse and Neglect," indicated that the facility screens potential employees for a history of abuse, neglect, or mistreatment of residents and potential employees are fingerprinted through live scan. b. During an interview with a Certified Nursing Assistant (CNA) 1 on 5/21/17 at 6:47 a.m., CNA 1 stated that all allegations of abuse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 10 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 should be reported to the ombudsman and police within two hours if there is serious physical injury, and all other allegations that does not have serious physical injury should be reported within twenty four hours. CNA 1 was asked if there is another government agency that she should report allegations of abuse, CNA 1 stated just the police and the ombudsman. During an interview with the activity leader on 5/21/17 at 8:20 a.m., the activity leader stated that all allegations of abuse must be reported to the police via 911 and to the ombudsman. The Activity leader also stated that reporting should be done within 2 hours if there is harm; if the allegation of abuse was not serious, reporting should be done within 24 hours. The activity leader was asked if there is another government agency that she should report allegations of abuse, the activity leader stated that is it, just the police and ombudsman. A review of an undated facility's policy and procedure titled, "Reporting Abuse to Facility Management" indicated that when an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility's administrator, or his/her designee, will notify the following persons or agencies of such incident within twenty-four (24) hours as deemed appropriate based on initial investigation: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; g. The Facility Medical Director. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 11 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: THR311 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA950000039 (X5) COMPLETE DATE If continuation sheet 12 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F241 DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/05/2017 (a)(1) A facility must treat 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide care in a manner and in an environment that maintains the resident's dignity. Registered nurse (RN1) was observed standing while feeding two residents. Findings: On 5/19/17 at 5:25 p.m., during dinner observation, RN1 was observed standing while feeding two residents with soup. On 5/19/17 at 5:35p.m., an interview was conducted with RN1 who stated she should have sat down while feeding the residents. The licensed staff stated feeding residents while sitting allows more time for the residents to feel relaxed and not rushed during feeding. The licensed staff also stated there was no chair available for her to use. A review of the facility's policy and procedure titled "Assistance with Meals" revised on September 2013 indicated residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 13 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F250 PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.40(d)

F250 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/20/2017 (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents' personal belongings were returned to the resident or family, for two of three discharged residents (Residents 14 and 16) from a total of 19 sampled residents. Findings: a. A review of the Admission face sheet indicated Resident 14 was admitted to the facility on 3/16/17, with diagnoses of malignant neoplasm of the larynx (abnormal growth of cells that can invade nearby tissues of the voice box), cardiomyopathy (disease of the heart muscle that may cause shortness of breath, chest pain, and fatigue), and hypertension (high blood pressure). Resident 14 expired on 3/19/17. A review of Resident 14's inventory list indicated it was completed upon admission on 3/16/17 which showed 3 undershirts, 1 copper band, and 1 speaker valve. The inventory list was signed by the facility's representative only. The lines for Resident/Responsible party signature and reason if resident was unable to sign were blank. Further review indicated that the inventory list upon discharge was not completed. On 5/21/17 at 10:05 a.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 14 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 record review and interview with the director of nursing (DON), she stated that the inventory list was not completed after Resident 14 had expired. The DON stated Resident 14 does not have a family who could have signed the inventory list, but the facility should not have left it blank, but should have documented that Resident 14's belongings were kept in the facility in case a family member shows up at a later time. The DON stated that it was the nursing staff's responsibility to complete the inventory list upon admission and discharge and the Social Service Director (SSD) should have ensured its completion. A review of the facility's policy and procedure titled, "Personal Property," dated 9/2012, indicated the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. A review of another facility's policy and procedure titled, "Transfer or Discharge Documentation," dated 8/2014, indicated that when a resident is transferred or discharged, a documentation from the care planning team concerning all transfers must include the disposition of the resident's personal effects. b. A review of the Admission face sheet indicated Resident 16 was admitted to the facility on 2/12/17, with diagnoses of pulmonary fibrosis (condition in which the tissue deep in your lungs becomes scarred over time) and weakness. Resident 16 was transferred to the acute general hospital on 2/19/17. A review of Resident 16's inventory list indicated it was completed upon admission on 2/12/17, which showed 7 blouses, 1 hat, 3 jackets, 3 pairs of tennis shoes, 5 slacks, 1 pair of slippers, 5 pairs of socks, 1 sweater, 2 undershirts , and 7 underwear. The inventory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 15 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 list was signed by Resident 16 and the facility's representative only on admission. Further review indicated that the inventory list was signed by Resident 16's son upon discharge, but there was no documentation as to what personal belongings were returned. On 5/21/17 at 10:20 a.m., during a concurrent record review and interview with the director of nursing (DON), she stated the inventory list was not completed upon discharge of Resident 16 to GACH. The DON stated that Resident 16's inventory list should have been completed, and added that it was the nursing staff's responsibility to complete the inventory list upon admission and discharge, and the Social Service Director (SSD) should have ensured its completion. A review of the facility's policy and procedure titled, "Personal Property," dated 9/2012, indicated that the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. A review of another facility's policy and procedure titled, "Transfer or Discharge Documentation," dated 8/2014, indicated that when a resident is transferred or discharged, a documentation from the care planning team concerning all transfers must include the disposition of the resident's personal effects.

F253 SS=E HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.10(i)(2)

F253 06/08/2017 (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 16 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 provide an effective housekeeping and maintenance services. 1. The shower room in area called Fox 2 did not have a shower curtain. 2. The window screen was not secured in the room for Resident 5. Findings: 1. On 5/20/17 at 11:20 a.m., during the general observation of the facility with maintenance Staff 1, the shower room in Fox 2 did not have a shower curtain. Eight shower hooks were left hanging from the shower rack attached to the ceiling but there was no shower curtain available. On 5/20/17 at 11:30 a.m., an interview was conducted with maintenance Staff 1 who confirmed there was no shower curtain in the shower room in Fox 2. The maintenance staff indicated there should be a shower curtain in the shower room to prevent the residents from being exposed when care and bathing is provided by staff. A review of the facility's policy and procedure titled" Quality of Life-Dignity" revised August 2009, indicated staff shall promote, maintain and protect residents' privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. On 5/20/17 at 12:00 p.m., during the general observation of the facility with maintenance Staff 1, the window screen was observed not secured in the room for Resident 5. The window screen was detached from the window. A review of the clinical record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 17 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 5 was admitted to the facility on 3/23/13 and was readmitted on 2/13/17, with diagnosis that included hypertension (elevated blood pressure), major depressive disorder (persistent sadness and loss of interest), lack of coordination and difficulty walking. On 5/20/17 at 12:15 p.m., an interview was conducted with Resident 5. Resident 5 stated he reported the problem to one maintenance staff but did not hear back from the staff. Resident 5 stated he was concerned because the window screen was not secured, mosquitos and insects from outside might enter his room. On 5/20/17 at 12:25 p.m., an interview was conducted with maintenance Staff 1. The maintenance staff verified the window screen was detached from the window and was not secured. Maintenance Staff 1 indicated he will repair the detached window screen immediately. A review of the facility's policy and procedure title "Scheduled Maintenance" dated 03/11, indicated it is the policy of the Community Works Plant Operations Program to constantly monitor the conditions of the facility internally and externally. The purpose of this policy is to keep the facility and grounds maintained at all times to promote high aesthetic qualities and a safe environment for residents, staff, and visitors.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 06/08/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 18 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 19 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement the plan of care for one of 19 sampled residents (Resident 2). The facility staff did not notify the physician for Resident 2's weight gain of 7 pounds (lbs) as indicated on the care plan. This deficient practice had the potential for the resident not to receive the appropriate care and services. Findings: A review of the face sheet indicated Resident 2 was readmitted on 11/20/15, with diagnoses that included peripheral neuropathy (damage to or disease affecting nerves, which may impair sensation, movement, gland or organ function), diabetes mellitus (DM, chronic high blood sugar), dementia (decline in mental ability severe enough to interfere with daily life), and edema. A review of the quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 2/24/17 indicated Resident 2's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 7 (a score of 0 -7 represents severe cognitive impairment). It FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 20 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 also indicated that Resident 2 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, and bathing. A review of the facility form titled, "Vital Sign Record," indicated Resident 2's weight of 173 lbs on 4/5/17 and 180 lbs on 5/5/17, which was a 7 lb weight gain in a month. On 5/20/17 at 5:40 p.m., during concurrent record review and interview with the MDS coordinator, he verified that Resident 2 had a 7 lb weight gain as documented on the Vital Sign Record. The MDS coordinator stated that the space for physician notification date was blank on 5/15/17. He also verified that there were no documentation in Resident 2's clinical record that the physician was notified. On 5/20/17 at 6:25 p.m., during an interview, registered dietitian (RD) stated that the physician is notified for a significant weight change which is 5% in a month, 7.5% in 3 months and 10% in 6 months, but some residents have a care plan to notify the physician of weight gain or loss of 5 lbs or more. A review of Resident 2's care plan titled, "At Risk for Dehydration Related to Use of Diuretic due to Congestive Heart Failure (CHF, heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen)," dated 12/14/16 indicated staff interventions included to monitor monthly weight and inform physician of weight gain or loss of 5 lbs or more. On 5/21/17 at 9:00 a.m., during interview, licensed nurse (LVN 4) stated that the residents' care plan are formulated from individualized resident problems and diagnosis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 21 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 LVN 4 stated the interventions should be followed as indicated. The facility's policy and procedure titled, "Care Plans," dated 9/2010 indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. It also stipulated that care plan interventions are designed after careful consideration of the relationship between the resident's problem areas ad their causes. The policy also indicated that the identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes. No single discipline can manage the task in isolation. The resident's physician is integral to this process.

F314 SS=E TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 05/22/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 22 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide the necessary treatment and services to promote healing and prevent new ulcers from developing for two of four residents (Residents 10 and 17), who were at high risk for developing pressure ulcer, in a total sample of 19 residents. a. For Resident 10, left heel was not off-loaded (elevated to relieve pressure) and was observed to be resting on the footrest of the wheelchair. b. For Resident 17, a stage 2 pressure ulcer on the left inner buttock was observed with no current treatment order and bilateral heel protectors were not applied as ordered. These deficient practices had the potential to result in worsening of existing pressure ulcers and the development of new pressure ulcers. Findings: a. A review of Resident 10's profile face sheet indicated Resident 10 was admitted to the facility on 2/11/17 with diagnoses that included dementia (brain disorder that is characterized by long term and gradual decrease in the ability to think and remember), anxiety disorder (a mental disorder emotion characterized by an unpleasant state of inner uncertainty and fear), muscle weakness and urinary retention. A review of Minimum Data Set (MDS), a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 23 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 comprehensive assessment and care tracking tool, dated 1/24/17 indicated Resident 10 had a brief interview for mental status (BIMS screens for cognitive impairment) score of 5 (a score of 0-7 indicates severe cognitive impairment), required extensive assistance with one-person assist for bed mobility, transfer, ambulation, hygiene and bathing. A review of Resident 10's physician telephone order dated 5/5/17 indicated an order of Skilcare Heels Off (a foam to position and stabilize legs to offload both heels for total pressure relief), apply to bilateral feet to be off-load. During an observation of Resident 10 on 5/21/17 from 6:45 p.m. to 7:15 p.m., Resident 10 was observed sitting up on a wheelchair at bedside. Resident 10 was observed wearing shoes with bilateral heels resting on the footrest of the wheelchair. Resident 10's left heel was observed with a black hard material covering the left heel. Skil-care heels off foam was observed on top of the bedside table. During an interview with the treatment nurse on 5/21/17 at 7:15 p.m., treatment nurse stated that Skil-care Heels Off should also be applied while Resident 10 is up on the wheelchair to relieve pressure on bilateral heels. Treatment nurse further stated that Resident 10's left heel pressure ulcer could get worse if pressure on left heel is not relieved. During an interview with CNA 2 on 5/21/17 at 7:25 p.m., CNA 2 stated that she was the one who brought Resident 10 back to room. CNA 2 also stated that Resident 10's Skil-care Heels Off foam was not on Resident 10's bilateral feet. CNA 2 further stated that she was not the one who removed the Skil-Care Heels Off foam. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 24 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 10's Pressure Injury Care Plan dated 5/5/17 indicated Resident 10 had a left heel DTI (deep tissue injury), one of the interventions is to apply Skil-Care heels Off to bilateral feet to off load for pressure relief. A review of facility's policy and procedure titled, "Prevention of Pressure Ulcers", dated 9/2013 indicated interventions and preventive measures for a person in a chair is to use foam, gel or air cushion as indicated to relieve pressure. b. A review of Resident 17's profile face sheet indicated Resident 17 characterized by frequent urination, increased thirst, and increased hunger) type 2 and dysphagia (difficulty swallowing). A review of Resident 17's "Physician Orders" for the month of May 2017 indicated an order started on 4/22/16 to apply heel protector to bilateral feet for pressure relief. A review of MDS dated 3/10/17 indicated Resident 17 was rarely/never understood and rarely/never understands others; had severely impaired cognitive skills for decision making, was totally dependent with one person assist with toilet use, personal hygiene and bathing; was incontinent of bowel and bladder. A review of Resident 17's "Braden Scale for Predicting Pressure Sore Risk" dated 3/9/17 indicated Resident 17 had a score of 12 (if score is 16 or less, consider resident at risk for pressure ulcer development). A review of Resident 17's "Weekly Summary" dated 5/17/17 indicated Resident 17 had no skin ulcers, no skin problems. During a concurrent observation of Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 25 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 interview with CNA 3 on 5/21/17 at 7:45 a.m., Resident 17 was observed in a right sidelying position in bed. CNA 3 verified that there was no bilateral heel protectors on to Resident 17. Bilateral heels was observed directly touching the bed. Resident 17 was observed with a left inner buttock pressure ulcer. During an interview with LVN 4 on 5/21/17 at 7:55 a.m., LVN 4 verified that Resident 17 has a stage 2 pressure ulcer on left inner buttocks. LVN 4 also stated that facility now uses the term pressure injury instead of pressure ulcer. LVN 4 also stated that she will inform the attending physician to get treatment orders for the new skin condition. During an interview with CNA 4 on 5/21/17 at 8:47 a.m., CNA 4 stated that she changed Resident 17's diaper around 6:30 a.m. but did not notice any skin breakdown. CNA 4 also stated that she reports to the charge nurse for any new skin condition at the end of the shift. During an interview with LVN 3 on 5/21/17 at 8:55 a.m., LVN 3 stated that the facility does not know when the stage 2 pressure ulcer for Resident 17 started. LVN 3 also stated that Resident 17's stage 2 pressure ulcer could not have happened between 6:30 a.m. (time Resident was last seen by a facility staff) and 7:45 a.m. (time the stage 2 pressure ulcer on the left inner buttock was identified). LVN 3 further stated that facility does not document for monitoring of bilateral heel protectors if it was applied to the resident. During an interview with the DON on 5/21/17 at 10:30 a.m., DON stated that CNAs perform the daily body check but does not document on the clinical record if there is no new skin breakdown; LVNs perform weekly body check and is part of the weekly assessment of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 26 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 LVNs. A review of Resident 17's "Pressure Ulcer Care Plan" dated 3/27/17 indicated that the goal for Resident 17 is to minimize risk for pressure ulcer formation and impaired skin integrity; approaches included licensed nurses to monitor skin condition weekly when doing weekly summary and CNA everyday during daily care, apply heel protector to both feet for pressure relief, monitor for any skin discoloration or breakdown and notify MD if noted. A review of facility's policy and procedure titled, "Prevention of Pressure Ulcers", dated 9/2013 indicated the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed.

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 06/08/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 27 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide an environment that is free from accident/hazards by not implementing interventions to prevent accidents/hazards for 3 out of 19 sample residents (Residents 8, 11 and 12). a. For Resident 12, the facility failed to keep the resident's bed in a low position as indicated on the care plan. b. For Residents 8 and 11, the facility failed to provide floor mats as indicated on the care plan. These deficient practices had the potential to result in injury and/or harm to the Residents 8, 11 and 12. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 28 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 Findings: a. Resident 12 was readmitted to the facility on 12/15/16 with diagnoses that included hypertension (high blood pressure), atrial fibrillation (irregular heart beat), lack of coordination, difficulty walking, and muscle weakness. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/17/17 indicated Resident 12 had moderate cognitive skills for daily decision making and required various level of assistance with activities of daily living. Resident 2 was frequently incontinent of urine with a diagnosis of overactive bladder (condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life). Resident 2 also had an incident of fall with minor injury during the assessment reference period. A review of the facility form titled, "Weekly Summary," dated 5/12/17 indicated that Resident 2 had both short and long term memory loss. Resident required supervision with toilet use and limited assistance with bed mobility, transfer, and dressing. A review of the facility form titled, "Morse Fall Scale Assessment," dated 3/17/17 indicated a score of 55 (a score of 51 or above indicated high risk for fall). On 5/21/17 at 6:43 a.m., during concurrent observation and interview with certified nurse assistant (CNA 5), Resident 2 was observed lying in bed sleeping with bed not in low position. CNA 5 stated bed should have been in a low position to prevent fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 29 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 care plan titled, "At Risk for Increased Fall and Injury," dated 1/3/17, indicated Resident 2 required extensive assistance with bed mobility and transfer. Resident 2 also had a history of fall, with impaired safety awareness. Care plan indicated staff interventions included to provide adequate, glare free lighting, floors free from spills or clutter and keep bed in low position to minimize risk for fall or injury. On 5/21/17 at 9:05 a.m., during concurrent record review and interview with licensed nurse (LVN 4), she stated that Resident 12's care plan intervention to keep bed in low position should have been followed as indicated to prevent fall or injury. LVN 4 stated Resident 12 had an incident of fall on 12/20/16, but could not find a care plan for the fall. LVN 4 stated each time a resident falls, the care plan should be revised in order to be able to document the reason for fall, revise the interventions as needed to prevent fall from occurring again. The facility's policy and procedure titled, "Managing Falls and Fall Risk," dated 12/2007 indicated that the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident falling and try to minimize complications from falling. The facility's policy and procedure (P&P) titled, "Comprehensive Care Plans," dated 9/2010 indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. It also stipulated that care plan interventions are designed after careful consideration of the relationship between the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 30 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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's problem areas and their causes. The policy also indicated that the identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. P&P also indicated that assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. b. A review of Resident 8's profile face sheet indicated Resident 8 was admitted to the facility on 9/4/13 with diagnoses that included hypertension (chronic elevated blood pressure), dementia (brain disorder that is characterized by long term and gradual decrease in the ability to think and remember), muscle weakness and heart failure (heart is unable to pump sufficiently to maintain blood flow to meet the body's needs). A review of Resident 8's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool dated 3/2/17, indicated Resident 8 had a brief interview for mental status (BIMS- screens for cognitive impairment) score of 5 (a score of 0-7 indicates severely impaired cognition), required extensive assistance with two-person assist for transfer and toilet use, required extensive assistance with one-person assist for toilet use, hygiene and bathing. On 5/18/17 at 8:18 p.m., during concurrent observation and interview with LVN 5, Resident 8 was observed lying in bed sleeping with bed in a low position and no floor mat at bedside. LVN 5 stated that Resident 8 was at risk for fall . LVN 5 also stated that Resident 8 needed a floor mat at bedside to prevent injury. LVN 5 looked for the floor mat and observed floor mat placed by the wall near the door. LVN 5 further stated that the certified nursing assistant put FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 31 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 8 back to bed and must have forgotten to place the floor mat back at bedside. A review of the care plan titled, "At Risk for Increased Fall and Injury," dated 9/21/16, indicated Resident 8 required extensive assistance with transfers. Care plan indicated staff interventions included to keep bed in low position and fall mat at bedside. The facility's policy and procedure titled, "Managing Falls and Fall Risk," dated 12/2007 indicated that the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident falling and try to minimize complications from falling. c. A review of Resident 11's profile face sheet indicated Resident 11 was admitted to the facility on 1/9/2014 with diagnoses that included cerebral infarction (brain injury resulting from decreased blood supply and oxygen), hypertension (chronic elevated blood pressure), Alzheimer's disease (brain disorder that is characterized by long term and gradual decrease in the ability to think and remember) and hyperlipidemia (elevated fats in the blood). A review of Resident 11's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool dated 4/13/17 indicated Resident 11 had a brief interview for mental status (BIMS- screens for cognitive impairment) score of 3 (a score of 0-7 indicates severely impaired cognition), required extensive assistance with 2 person assist for transfer and toilet use. On 5/18/17 at 8:42 p.m., during concurrent observation and interview with LVN 5, Resident 11 was observed lying in bed sleeping with bed in a low position and bed alarm in place. LVN 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 32 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 stated that Resident 11 was at risk for fall . LVN 5 also stated that Resident 11 needed a floor mat at bedside to prevent injury. LVN 5 further stated that she will get a floor mat now and place it to Resident 11's bedside. A review of the care plan titled, "At Risk for Increased Fall and Injury," dated 1/31/17, indicated Resident 11 required extensive assistance with most ADL's (activities of daily living). Care plan indicated staff interventions included to provide adequate, glare free lighting, floors free from spills or clutter and keep bed in low position and fall mat at bedside. The facility's policy and procedure titled, "Managing Falls and Fall Risk," dated 12/2007 indicated that the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident falling and try to minimize complications from falling.

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 06/08/2017 (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. (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 33 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to store and protect food under sanitary conditions in the facility's walk-in refrigerator. This improper food safety practice could lead to possible food borne illness and/or food contamination. Findings: During the initial tour of the kitchen with the dietary staff on 5/18/17 at 7:35 p.m., walk-in refrigerator was inspected. Temperature inside the walk-in refrigerator was observed at 35 degrees Fahrenheit (F) and verified with the dietary staff. A bouquet of flowers was observed in a 5-gallon bucket half-filled with water. Bouquet of flowers was observed beside a pan of marinated raw meat that was covered. The bouquet of flowers was observed touching the pan of raw meat. Further inspection of the walk-in refrigerator showed 3 trays of unlabeled and undated dessert in a cart inside the refrigerator. During an interview with the dietary staff on 5/18/17 at 7:40 p.m., dietary staff stated that it is in the facility's policy and procedure that they could keep flowers inside the walk-in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 34 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 refrigerator. Dietary staff stated that the unlabeled dessert was mandarin oranges from a can that was placed in small bowls. Dietary staff stated that they just prepared the dessert today and will label it now. During an interview with the Registered Dietician (RD) on 5/19/17 at 5:10 p.m., RD stated that she will check the facility's policy and procedure to check if flowers could be stored in the refrigerator. A review of an undated facility policy and procedure titled, "Food Supply and Storage", indicated that flowers can be stored in buckets of water in the refrigerator, in the produce section not near ready to eat foods. Water must be changed daily. During another interview with the RD on 5/21/17 at 5:30 p.m., RD stated that produce, as indicated in the facility's policy and procedure, meant fruits and vegetables. RD also stated that the flowers inside the refrigerator should not be placed beside the marinated raw meat section. RD also stated that meat is not considered a produce. RD also stated that she will provide in-service to dietary staff regarding placement of flowers inside the walk-in refrigerator. RD also stated that labeling of food must be done after preparation and label should include the date the food was prepared or opened and the date of expiration. RD further stated that for canned fruits once opened, the expiration is 3 days from the date it was opened. A review of facility's policy and procedure titled, "Refrigerated Storage Life of Foods", dated 1/2017 indicated to use manufacturer's date for products before they are opened, label when product is opened, canned pudding, fruits and vegetables + (plus) 3 days from date opened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 35 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F425 PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/08/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on interview and record review, facility failed to ensure medications were administered according to the physician's order to three of 19 sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in a decline in the resident's well-being and for medication error to occur. a. Resident 1 had no documented evidence that the resident received Simvastatin (medication to lower the level of cholesterol), Remeron (medication to treat depression, a mood disorder that causes a persistent feeling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 36 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 of sadness and loss of interest), Buspar (medication to treat anxiety, state of excessive uneasiness and apprehension), Vitamin D3 (supplement), and Bimatoprost eye drops (medication to control the progression of glaucoma, eye diseases which result in damage to the optic nerve and vision loss) as ordered by the physician. b. Resident 2 had no documented evidence that the resident received Neurontin (medication to treat peripheral neuropathy [damage to or disease affecting nerves, which may impair sensation, movement, gland or organ function]), Vitamin B12 (supplement) , Zinc (supplement) , and Tramadol () as ordered by the physician. c. Resident 3 had no documented evidence that the resident received Albuterol (medication used to treat wheezing and shortness of breath), Systane gel drops (medication for eye irritation due to dryness), and Potassium Chloride (medication used to prevent or to treat low blood levels of potassium) as ordered by the physician. Findings: a. A review of the face sheet indicated Resident 1 was readmitted to the facility on 6/7/15, with diagnoses that included anxiety (state of excessive uneasiness and apprehension), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (eye diseases which result in damage to the optic nerve and vision loss), osteoporosis (progressive bone disease that weakens bones and makes them susceptible to bone fractures). A review of the quarterly Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 37 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 (MDS, a standardized assessment and care screening tool) dated 2/23/17 indicated Resident 1's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 7 (a score of 0 -7 represents severe cognitive impairment). It also indicated that Resident 1 required limited to extensive assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and bathing. Resident 1's patient health questionnaire (PHQ-9, validated interview that screens for symptoms of depression) score was 2 (a score of 1-4 indicated minimal depression). A review of Resident 1's physician's order indicated the following: 1. Simvastatin (medication to lower the level of cholesterol) 5 milligrams (mg) tablet by mouth at bedtime on Saturday, Monday, Tuesday, and Thursday ordered on 8/14/15. 2. Remeron 15 mg by mouth at bedtime except on Mondays and Thursdays for depression manifested by poor appetite and withdrawal ordered on 9/23/14. 3. Remeron 7.5 mg by mouth at bedtime on Mondays and Thursdays for depression manifested by poor appetite and withdrawal ordered on 9/23/14. 4. Buspar 5 mg by mouth twice a day for anxiety manifested by confusion and delusions in the evening ordered on 9/10/14. 5. Vitamin D3 1,000 units 4 tablets (4,000 units) by mouth daily for diagnosis of osteoprosis ordered on 4/30/17. 6. Bimatoprost 0.03% ophthalmic drops 1 drop to both eyes at bedtime for diagnosis of glaucoma ordered on 5/8/17. On 5/19/17 at 8:00 p.m., during concurrent record review and interview with licensed nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 38 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 (LVN 8), she stated that Resident 1's medication administration record (MAR) was not initialed for the following medications on the following dates: 1. Simvastatin 5 mg tablet by mouth at bedtime on Saturday, Monday, Tuesday, and Thursday not initialed on 5/8/17 and 5/18/17 at 9:00 p.m. 2. Remeron 15 mg by mouth at bedtime except on Mondays and Thursdays for depression manifested by poor appetite and withdrawal not initialed on 5/2/17, 5/3/17, and 5/15/17 at 9:00 p.m. 3. Remeron 7.5 mg by mouth at bedtime on Mondays and Thursdays for depression manifested by poor appetite and withdrawal not initialed on 5/8/17 at 9:00 p.m. 4. Buspar 5 mg by mouth twice a day for anxiety manifested by confusion and delusions in the evening not initialed on 5/15/17 at 5:00 p.m. 5. Vitamin D3 1,000 units 4 tablets (4,000 units) by mouth daily not initialed on 5/9/17, 5/17/17 and 5/18/17 at 9:00 a.m. 6. Bimatoprost 0.03% ophthalmic drops 1 drop to both eyes at bedtime for diagnosis of glaucoma not initialed on 5/16/17 and5/17/17 at 9:00 p.m. On 5/19/17 at 8:24 p.m., during interview, LVN 9 stated that after administration of medication as ordered by the physician, the licensed nurse should initial the MAR to confirm that the medication was given. LVN 9 stated that the MAR for Resident 1 should have been initialed by the licensed nurse to confirm that the medications were administered. A review of Resident 1's care plan titled, "Impaired Vision due to Glaucoma," dated 6/15/16 indicated staff interventions included to monitor for gradual loss of peripheral vision and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 39 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 administer Bimatoprost 0.03% ophthalmic drops 1 drop to both eyes at bedtime for diagnosis of glaucoma. A review of Resident 1's care plan titled, "Resident Has Expressed Having Days of Depression," dated 6/15/16 indicated staff interventions included maintain consistency in daily routine and administer medications as ordered. A record review of the facility's policy and procedure titled, "Medication Orders," dated 4/2008, indicated medications are administered upon the clear complete, and signed order of a person lawfully authorized to prescribed. b. A review of the face sheet indicated Resident 2 was readmitted on 11/20/15, with diagnoses that included peripheral neuropathy (damage to or disease affecting nerves, which may impair sensation, movement, gland or organ function), diabetes mellitus (DM, chronic high blood sugar), dementia (decline in mental ability severe enough to interfere with daily life), and edema. A review of the quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 2/24/17 indicated Resident 2's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 7 (a score of 0 -7 represents severe cognitive impairment). It also indicated that Resident 2 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, and bathing. Resident 2 complained of occasional pain during the assessment reference period. A review of Resident 2's physician's order indicated the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 40 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 1. Neurontin 100 milligrams (mg) 1 capsule by mouth three times a day for peripheral neuropathy ordered on 11/20/15. 2. Vitamin B12 500 microgram (mcg) 1 by mouth daily for supplement ordered on 11/24/15. 3. Zinc 220 mg 1 tablet by mouth daily for supplement ordered on 4/4/17. 4. Tramadol 50 mg 1 tablet by mouth four times a day for moderate pain not ordered on 4/8/17. On 5/19/17 at 7:52 p.m., during concurrent record review and interview with licensed nurse (LVN 8), she stated that Resident 2's medication administration record (MAR) was not initialed for the following medications on the following dates: 1. Neurontin 100 milligrams (mg) 1 capsule by mouth three times a day for peripheral neuropathy not initialed on 5/2/17 at 1:00 p.m. 2. Vitamin B12 500 microgram (mcg) 1 by mouth daily for supplement not initialed on 5/2/16 at 12:00 p.m. 3. Zinc 220 mg 1 tablet by mouth daily for supplement not initialed on 5/18/17. 4. Tramadol 50 mg 1 tablet by mouth four times a day for moderate pain not initialed on 5/10/17 at 12:00 a.m. On 5/19/17 at 8:14 p.m., during interview, LVN 9 stated that after administration of medication as ordered by the physician, the licensed nurse should initial the MAR to confirm that the medication was given. LVN 9 stated that the MAR for Resident 2 should have been initialed by the licensed nurse to confirm that the medications were administered. LVN 9 stated it would be difficult to confirm that the medications were given because the medication bubble pack for the date with missing initials had been discarded and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 41 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 other medications were in a medication house supply bottle. A review of Resident 2's care plan titled, "Potential for Increased Pain and Discomfort," dated 12/14/16 indicated staff interventions included to provide/encourage rest periods during the day as needed and administer Tramadol 50 mg 1 tablet by mouth four times a day for moderate pain. A review of Resident 2's care plan titled, "Resident is at Nutrition Risk," dated 12/14/16 indicated staff interventions included diet as ordered and administer Zinc 220 mg 1 tablet by mouth daily for supplement. A record review of the facility's policy and procedure titled, "Medication Orders," dated 4/2008, indicated medications are administered upon the clear complete, and signed order of a person lawfully authorized to prescribed. c. A review of the face sheet indicated Resident 3 was readmitted on 8/18/17, with diagnoses that included hypertension (high blood pressure), chronic obstructive pulmonary disease- lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult, and anxiety disorder (state of excessive uneasiness and apprehension). A review of the quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/11/17 indicated Resident 3's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 9 (a score of 8 -12 represents moderate cognitive impairment). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 42 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 It also indicated that Resident 3 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and bathing. A review of the physician's order revealed the following: 1. Albuterol 2.5 milligrams (mg)/ 3 milliliters (ml) normal saline 1 unit dose (UD) via hand held nebulizer (HHN) inhalation solution 0.083% four times a day ordered on 3/3/15. 2. Systane gel drops 1 drop to both eyes every 3 hours while awake for eye irritation due to dryness ordered on 5/1/15. 3. Potassium Chloride 10 milliequivalent (meq) 3 tablets by mouth twice a day for hypokalemia (low level of potassium) ordered on 1/18/17. On 5/19/17 at 8:30 p.m., during concurrent record review and interview with licensed nurse (LVN 8), she stated that Resident 3's medication administration record (MAR) was not initialed for the following medications on the following dates: 1. Albuterol 2.5 mg/ 3 ml normal saline 1 UD via HHN inhalation solution 0.083% four times a day not initialed on 5/2/17 and 5/18/17 at 1:00 p.m. 2. Systane gel drops 1 drop to both eyes every 3 hours while awake for eye irritation due to dryness not initialed on 5/2/17 at 1:00 p.m. 3. Potassium Chloride 10 meq 3 tablets by mouth twice a day for hypokalemia (low level of potassium) not initialed on 5/2/17 at 1:00 p.m. On 5/19/17 at 8:33 p.m., during interview, LVN 9 stated that after administration of medication as ordered by the physician, the licensed nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 43 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 should initial the MAR to confirm that the medication was given. LVN 9 stated that the MAR for Resident 3 should have been initialed by the licensed nurse to confirm that the medications were administered. A review of Resident 3's care plan titled, "Impaired Vision Related to Macular Degeneration (medical condition which may result in blurred or no vision in the center of the visual field)," dated 3/2/17 indicated staff interventions included to assess/record/report to physician visual changes or increase in visual problems and administer Systane gel drops 1 drop to both eyes every 3 hours while awake for eye irritation due to dryness. A review of Resident 3's care plan titled, "Potential for Respiratory Distress related to Asthma (long term inflammatory disease of the airways of the lungs) and COPD," dated 3/2/17 indicated staff interventions included to assess lung sounds, monitor for signs and symptoms of infection, and administer Albuterol 2.5 milligrams (mg)/ 3 milliliters (ml) normal saline 1 unit dose (UD) via hand held nebulizer inhalation solution 0.083% four times a day. A record review of the facility's policy and procedure titled, "Medication Orders," dated 4/2008, indicated medications are administered upon the clear complete, and signed order of a person lawfully authorized to prescribed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 44 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F431 DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/08/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 45 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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) Storage of Drugs and Biologicals. (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. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs 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. Residents requiring purified protein derivative (PPD, combination of proteins that are used in the diagnosis of tuberculosis [infectious disease affecting the lungs]) skin test were not administered with an expired PPD by failing to remove two vials of expired PPD in one of three medication refrigerators. This deficient practice had the potential for inaccurate skin test result in an event that the expired PPD vial was used to test for tuberculosis. b. Safe and secure storage of medication in 1 of 3 nursing stations. The treatment cart for one nursing station was left unlocked. c. An accurate reconciliation of medications of an Intramuscular (IM) Ekit (emergency kit). One vial of lidocaine (medication used to numb FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 46 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 tissue in a specific area) was missing in the IM Ekit for one of three medication rooms. This deficient practice could result in medication diversion. Findings: a. On 5/18/17 at 9:25 p.m, during an inspection of one of three medication rooms, the following were observed inside the medication refrigerator: 1. one undated vial of opened purified protein derivative (PPD, combination of proteins that are used in the diagnosis of tuberculosis [ TB, infectious disease affecting the lungs]) 2. one PPD vial with an opened date of 4/16/17 On 5/18/17 at 9:31 a.m., during concurrent record review of the PPD manufacturer's insert and interview with licensed vocational nurse (LVN 7), she stated that the PPD vial should have been dated after it was opened. LVN 7 also stated that since the PPD manufacturer's insert indicated PPD vials in use more than 30 days should be discarded due to possible oxidation (chemical reaction) and degradation (unwanted chemicals that can develop) which may affect potency (measure of drug activity expressed in terms of the amount required to produce an effect of given intensity), LVN 7 futher stated the PPD vial dated 4/16/17 should have been discarded. The facility's policy and procedure (P&P) titled, "Specific Medication Administration Procedures," dated 4/2008, indicated that it is the policy of the facility to administer medications in a safe and effective manner. P&P also stipulated that outdated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 47 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 contaminated, or deteriorated medications are immediately removed and disposed of according to procedures for medication disposal. b. On 5/18/17 at 7:10 p.m., during initial tour of the facility with registered nurse (RN1), the treatment cart in the facility area called Joslyn nursing station was observed unlocked. The lowest drawer of the treatment cart was left open. On 5/18/17 at 7:20 p.m., an interview was conducted with licensed vocational nurse (LVN 2) who confirmed the treatment cart was unattended and was left unlocked at Joslyn nursing station. LVN 2 indicated per policy, the treatment cart should be left locked at all times when not being used. LVN 2 stated the treatment cart was not in use but was left open. A review of the facility's policy and procedure titled" Specific Medication Administration Procedures", dated April 2008 indicated medication cart is locked at all times unless in use and under the direct observation of the medication nurse. c. During an inspection of the medication room in the facility area identified as Fox 2 nursing station with LVN 5 on 5/18/17 at 9:45 p.m., LVN 5 verified that the IM Ekit had a yellow zip tie. LVN 5 stated that a yellow zip tie meant that the Ekit was already opened. LVN 5 opened the IM Ekit to account for all the medications inside. LVN 5 verified that one vial of Lidocaine was missing inside the IM Ekit. LVN 5 also verified that the paper log that lists all medications removed from the IM Ekit was blank. LVN 5 stated that the lidocaine vial was used by one of the attending physicians. LVN 5 further stated that she was the one who removed the lidocaine and assisted the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 48 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 physician. LVN 5 also stated that she removed the lidocaine vial around 5:15 p.m. LVN 5 stated that she should have listed in the log the lidocaine vial she took prior to resealing the IM Ekit with the yellow zip tie. LVN 5 further stated that she was in a hurry and forgot to list on the log the medication she took in the IM Ekit. A review of facility's policy and procedure titled, Medication Ordering and Receiving from Pharmacy", dated 8/2014 indicated When an emergency or "stat" (immediate) order is received, the charge nurse: 1. Follows the procedure for order documentation in accordance with the policy on prescriberber medication orders.

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 06/08/2017 (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: (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 (facility assessment implementation is Phase 2); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 49 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 (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 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. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 50 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 spread of infection. (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: Based on observation, interview, and record review, the facility failed to implement and maintain its infection control program to prevent the potential spread and/or transmission of infection. During an observation of the medication room in one of three nursing stations, one pack of ice cream was observed inside the freezer of the medication refrigerator. This deficient practice had the potential for contamination and infection. Findings: On 5/18/17 at 9:20 p.m., during an observation of the medication room with licensed vocational nurse (LVN 1) in Joslyn nursing station, one pack of ice cream was observed inside the freezer of the medication refrigerator. The medication refrigerator contained one emergency medication kit, one glucagon injectable, one Humalog injectable, eight unopened influenza vaccine vials, and one opened tuberculin injectable and three unopened tuberculin injectables. On 5/18/17 at 9:30 p.m., an interview was conducted with LVN 1 who indicated ice cream and food items should not be placed inside the medication room refrigerator. LVN 1 stated the medication room refrigerator is only for medication and not for food. LVN 1 indicated the ice cream must be thrown away immediately to prevent contamination and risk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 51 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 of infection. A review of the facility's policy and procedure titled" Medication Storage in The Facility", dated April 2008 indicated refrigerated medications are kept in closed and labeled containers, with internal and external medications separated from juices, applesauce and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator.

F465 SS=E SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) 06/08/2017 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment to the residents regarding exposed jagged surface on the side of the countertop in one of three nursing stations. Findings: On 5/20/17 at 5:15pm, during a general observation of the facility with maintenance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 52 of 53 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: _______________ 555272 (X3) DATE SURVEY COMPLETED 05/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ATHERTON 214 S Atlantic Blvd Alhambra, CA 91801 (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 staff 1, an exposed jagged surface on the side of the countertop was observed at the Joslyn Nursing Station. On 5/20/17 at 5:30pm, an interview was conducted with maintenance staff 1 who confirmed the countertop was not in good repair with exposed jagged surface. Maintenance staff indicated the sharp edges had the potential to cause injury to residents. Maintenance staff stated he will fix the countertop as soon as possible. A review of the facility's policy and procedure title "Scheduled Maintenance" dated 03/11 indicated it is the policy of the Community Works Plant Operations Program to constantly monitor the conditions of the facility internally and externally. The purpose of this policy is to keep the facility and grounds maintained at all times to promote high aesthetic qualities and a safe environment for residents, staff, and visitors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THR311 Facility ID: CA950000039 If continuation sheet 53 of 53