Inspection·November 3, 2023

F 0550 policy statement that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy indicated the following: Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Few Residents shall be treated with dignity and respect at all times. 2. Treated with dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 2 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light is within the resident's reach for two of two sampled residents (Resident 36 and Resident 50). Residents Affected - Few This deficient practice had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries. Findings: A review of Resident 36's admission Record indicated the facility admitted the resident on 9/13/2021, with diagnoses including schizoaffective disorder, depressive type (a mental health disorder with symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 36 had the ability to make self-understood and understand others. The MDS indicated the resident required supervision with bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 36's Care Plan, dated 9/14/201 , indicated Resident 36 was at risk for falls related to multiple medications use, decreased safety judgment secondary to psychiatric issues. The interventions included to encourage the resident to use call light for assistance as needed and to respond promptly to all requests for assistance. During a concurrent observation and interview on 10/31/2023 at 10:30 a.m., with Activity Assistant 3 (AA 3), observed Resident 36's call light hanging on the wall behind the resident's bed. AA 3 stated the call light should be within the resident's reach and not hung on the wall because there is a potential for the resident to fall while trying to reach for the call light. A review of Resident 50's admission Record indicated the facility admitted the resident on 7/22/2022, with diagnoses including hemiplegia and hemiparesis affecting the left side (a condition in which one side of the body is weak and not able to move), and legal blindness (having only 10% of your vision). A review of Resident 50's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/2023, indicated Resident 50 had the ability to make self-understood and understand others. The MDS indicated Resident 50 required supervision with bed mobility, transfer, walk in room, locomotion on and off unit, and eating. A review of Resident 50's Care Plan, dated 7/10/2020, indicated Resident 50 was at high risk for falls related to history of fall, legal blindness, and getting up unassisted. The interventions included to maintain call light within reach and answer promptly. During a concurrent observation and interview on 10/31/2023 at 10:21 a.m., with Certified Nursing Assistant 6 (CNA 6), observed Resident 50's call light on the floor. CNA 6 stated it is important that the call light is within reach so the resident can call for assistance. CNA 6 stated the resident can fall while trying to reach for the call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 3 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/2/2023 at 1:33 p.m., with the Director of Development (DSD), the DSD stated the call light is the resident's lifeline and should have been placed within reach so the residents can communicate their needs to the staff. The DSD stated not having the call light within the resident's reach had the potential for the residents hurting themselves trying to reach for the call light. During an interview on 11/3/2023 at 10:28 a.m., with the Director of Nursing (DON), the DON stated the call light should be within reach, so the residents are able to ask staff for assistance. The DON stated not having the call light within reach had the potential for residents' needs not being met and may result in fall related injuries. A review of a facility policy and procedure titled, Call System, last revised on 03/2023, indicated to provide a mechanism for residents to communicate to staff a need for assistance and make sure all cords are placed within the resident's reach at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 4 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for three (3) of 3 sampled residents (Residents 51, 53, and 55) investigated under the Restraint care area by: Residents Affected - Some 1. Failing to ensure least restrictive measures were attempted prior to use of self-release belt alarm and sensor pad alarm in bed to ensure the alarms were used to treat medical symptoms and not for discipline or convenience, for Resident 51. 2. Failing to ensure least restrictive measures were attempted prior to use of self-release belt alarm and failing to ensure the informed consent was clarified with the physician for the use of self-release belt alarm, to ensure the self-release belt alarm was used to treat medical symptoms and not for discipline or convenience, for Resident 53. 3. Failing to ensure least restrictive measures were attempted prior to use of pressure alarm in wheelchair and failing to ensure the informed consent for the use of pressure alarm in wheelchair and in bed was clarified with the physician prior to use, to ensure the alarms were used to treat medical symptoms and not for discipline or convenience, for Resident 55. These deficient practices placed Residents 51, 53, and 55 at risk for affecting their self-worth for being restricted with movement and had the potential to violate the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Findings: a. A review of Resident 51's admission Record indicated the facility admitted the resident on 5/21/2018 and readmitted the resident on 9/27/2021 with diagnoses including cerebral infarction (also known as a stroke which occurs due to damage to tissues in the brain due to a loss of oxygen), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks(, and history of falling. A review of Resident 51's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/26/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial assistance from staff eating, persona hygiene, and bed mobility, and total assistance from staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 51's Order Summary Report indicated the following orders: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 5 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident may have self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted. Check for placement and functionality every shift dated 9/28/2021. 2. Resident may have sensor pad alarm in bed, to alert staff in unassisted transfer. Check for placement and functionality every shift dated 9/27/2021. A review of Resident 51's care plan indicated Resident was a high risk for further falls related to impaired cognition, and Alzheimer's initiated 5/22/2018 with target date of 1/24/2024, indicated the resident's last documented fall incident was 3/7/2022. The care plan indicated use of appropriate device as ordered, self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted. A review of Resident 51's Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drugs or Prolonged Use of a Device dated 9/28/2021, indicated the following: 1. May have self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted. 2. May have sensor pad alarm in bed to alert staff in unassisted transfer. A review of resident 51's quarterly Restraints-Physical Assessments dated 10/31/2022, 1/27/2023, 10/26/2023 did not indicate restraint reduction strategies and alternatives attempted prior to use of the self-release belt alarm and sensor pad alarm in bed. The restraint assessments indicated self-release belt alarm in wheelchair and sensor pad alarm in bed to remind himself or alert staff if Resident 51 attempts to get up by himself. The restraint assessments did not indicate restraint reduction strategies and alternatives attempted prior to use of the self-release belt alarm while in wheelchair and sensor pad alarm in bed. During a concurrent observation and interview on 10/31/2023 at 9:45 a.m., with Activity Assistant 1 (AA 1), observed Resident 51 in the wheelchair in the activity room with belt attached to an alarm box on the backrest of the wheelchair. Activity Assistant 1 (AA 1) stated the belt was an alarm to alert staff in case Resident 51 slides off the wheelchair. During an interview on 11/3/2023 at 8:00 a.m., with the Minimum Data Set Assistant (MDSA), the MDSA stated she may have forgotten to indicate in Resident 51's restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the self-release belt alarm. The MDSA stated she should have indicated in the restraints assessments the least restrictive measures attempted prior to use of the self-release belt alarm and sensor pad alarm. During a concurrent interview and record review on 11/3/2023 at 9:13 a.m., with the Director of Nursing (DON), Resident 51's informed consent, care plan, and quarterly restraint assessments were reviewed. The DON stated the informed consents for the self-release belt alarm in wheelchair and sensor pad alarm in bed indicated the reason for use of the alarms is to alert staff of Resident 51's attempts of standing up and transferring unassisted. The DON stated there was no documented evidence in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 6 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the care plan and restraint assessments that restraint reduction strategies and alternatives were attempted prior to use of the self-release belt alarm and sensor pad alarm. The DON verified the reason for the use of self-release belt alarm and sensor pad alarm was not due to a medical symptom. The DON stated the care plan and the quarterly restraint assessments should have indicated the least restrictive measures attempted to evaluate the need for continued use of the alarm. The DON stated continued use of the alarm may affect Resident 51's self- worth as his movement was restricted. The DON stated the informed consent should have been clarified with the physician to ensure the use of alarms was to treat the resident's medical condition. b. A review of Resident 53's admission Record indicated the facility admitted the resident on 6/4/2021 with diagnoses including hemiplegia (complete paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) affecting the right dominant side, dysphagia (difficulty swallowing), and dependence on wheelchair. A review of Resident 53's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/30/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with locomotion on and off unit, unable to walk, and required extensive assistance with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 53's Order Summary Report indicated an order, the resident may have self-release belt alarm in wheelchair, check for placement and functionality every shift dated 8/8/2023. A review of Resident 53's Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drugs or Prolonged Use of a Device dated 11/4/2021, indicated may use self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted, check for placement and functionality every shift. A review of Resident 53's care plan on risk for falls related to general muscle weakness, impaired cognition, right hemiplegia, and history of falls prior to admission initiated on 6/4/2021 and with target date of 2/27/2024, indicated an intervention may have self-release belt alarm when in wheelchair. A review of Resident 53's quarterly Restraints-Physical Assessments dated 12/2/2022, 3/2/2023, 6/2/2023, and 8/28/2023 did not indicate restraint reduction strategies and alternatives were attempted prior to use of the self-release belt alarm. The restraint assessments indicated self-release belt alarm in wheelchair use to alert staff of resident's activity as patient is non-ambulatory. During a concurrent observation and interview on 10/31/2023 at 9:08 a.m., with Activity Assistant 1 (AA 1), observed Resident 53 in the wheelchair in the activity room with belt attached to an alarm box. Activity Assistant 1 (AA 1) stated the belt was a self-release alarm to alert staff in case Resident 53 slides off the wheelchair. During an interview on 11/3/2023 at 8:00 a.m., with the Minimum Data Set Assistant (MDSA), the MDSA stated she may have forgotten to indicate in Resident 53's restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the self-release belt alarm. The MDSA stated she should have indicated in the restraints assessments the least restrictive measures attempted prior to use of the self-release belt alarm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 7 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 11/3/2023 at 9:13 a.m., with the Director of Nursing (DON), Resident 53's informed consent, care plan, and quarterly restraint assessments were reviewed. The DON verified the self-release belt alarm informed consent indicated the use of self-release belt alarm in wheelchair was to alert staff if the resident was trying to stand up unassisted. The DON stated there was no documented evidence in the care plan and restraint assessments that restraint reduction strategies and alternatives were attempted prior to use of the self-release belt alarm. The DON verified the reason for the use of self-release belt alarm was not treat a medical symptom. The DON stated the care plan and the quarterly restraint assessments should have indicated the least restrictive measures attempted to evaluate the need for continued use of the alarms. The DON stated continued use of the alarm may affect Resident 53's self- worth as his movement was restricted. The DON stated the informed consent should have been clarified with the physician to ensure the use of alarms was to treat the resident's medical symptom. c. A review of Resident 55's Face Sheet indicated the facility admitted the resident on 5/16/2022 with diagnoses including vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 55's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/27/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and locomotion in the unit, extensive assistance from staff with bed mobility, personal hygiene, and dressing, and totally dependent to staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 55's Order Summary Report indicated the following: 1. Resident may have alarm in bed to alert staff if resident was getting out of bed unassisted. Check for placement every shift dated 8/8/2023. 2. Resident may have pressure alarm in wheelchair to remind resident to call staff when in need of assistance and to alert staff of getting up unassisted. A review of Resident 55's Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drugs or Prolonged Use of a Device dated 2/19/2023, indicated wheelchair/bed alarm. A review of Resident 55's care plan on risk for falls related to gait/balance problems, decrease safety judgement, and history of falls prior to admission initiated on 5/22/2022 with a target date of 2/8/2024, indicated an intervention for bed alarm and wheelchair alarm to alert staff and to remind resident to ask for assistance. A review of Resident 55's quarterly Restraints-Physical Assessments dated 11/17/2022, 2/15/2023, 5/16/2023, and 8/16/2023 did not indicate restraint reduction strategies and alternatives attempted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 8 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prior to use of the self-release belt alarm. The restraint assessments indicated there was no behavioral problem, and restraint was not recommended. During a concurrent observation and interview on 10/31/2023 at 9:18 a.m., observed Resident 55 sitting in the wheelchair without a wheelchair alarm. Resident 55 stated he does not need a wheelchair alarm as he can get in and out of bed to the wheelchair safely. During a concurrent observation and interview on 10/11/2023 at 1:00 p.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 55's sensor pad alarm with blinking green light attached to the right side of the bed. LVN 3 stated the bed alarm alerts the staff if the resident is trying to get up unassisted. During an interview on 11/3/2023 at 8:00 a.m., with the Minimum Data Set Assistant (MDSA), the MDSA stated that she may have forgotten to indicate in Resident 55's restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the bed alarm. The MDSA stated she should have indicated in the restraints assessments the least restrictive measures have been attempted prior to use. During a concurrent interview and record review on 11/3/2023 at 9:13 a.m., with the Director of Nursing (DON), Resident 55's informed consent, care plan, and quarterly restraint assessments were reviewed. The DON verified the informed consent indicated wheelchair/bed alarm. The DON stated there was no documented evidence in the care plan and restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the pressure alarm in wheelchair and bed alarm. The DON verified the reason for the use of pressure alarm in wheelchair and bed alarm was not to treat a medical symptom. The DON stated the care plan and the quarterly restraint assessments should have indicated the least restrictive measures attempted to evaluate the need for continued use of the alarms. The DON stated continued use of the alarm may affect Resident 55's self- worth as his movement was restricted. The DON stated the informed consent should have been clarified with the physician to ensure the use of alarms was to treat the resident's medical symptom. A review of the facility's policy and procedure titled, Informed Consent for Physical/Chemical Restraints, last reviewed 3/9/2023, indicated the resident's attending physician has to inform the resident or surrogate of the risks and potential benefits of the use of chemical restraints, physical restraints, or devices that may lead to the inability to regain use of a normal bodily function. The policy indicated use of devices that may lead to the inability to regain normal bodily function will be only on written physician's order. A review of the facility's policy and procedure titled, Use of Restraints, last reviewed 3/9/2023, indicated the following: 1. Restraints shall only be used after other alternatives have been tried unsuccessfully. 2. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by less restrictive intervention and a restraint is required to treat the medical symptom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 9 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 3. Level of Harm - Minimal harm or potential for actual harm Prior to placing a restraint, there shall be a pre-restraint assessment to review the need for restraint, to determine underlying causes of the medical symptom, and if there are less restrictive interventions that may improve the symptoms. Residents Affected - Some 4. Restraints shall only be used upon the written order of a physician and after obtaining consent and shall include the specific reason related to the medical symptoms, and how the restraint will be used to benefit the resident's medical symptoms. A review of the facility's policy and procedure titled, Alarms, Personal Use of, indicated that the facility use the least restrictive method of ensuring resident safety to provide the highest degree of resident independence possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 10 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on observation, interview, and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy and return for one out of five residents (Resident 70) investigated addressing the care area of hospitalization. Resident 70 was transferred from the facility to a general acute care hospital (GACH) on 10/30/2023. This deficient practice had the potential to deny Resident 70's timely return to the facility due to no available bed. Findings: A review of Resident 70's admission Record indicated the facility admitted the resident on 8/28/2020, with diagnoses including multiple left rib fractures, psychosis (a mental health condition when there is a loss of contact with reality), vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), and lack of coordination. A review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/21/2021, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance with bathing, limited assistance with dressing, toilet use, and personal hygiene, and supervision with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 70's physician's order dated 10/30/2023, indicated a telephone order to send the resident to the emergency room (ER) secondary to left ninth (9th) rib fracture, for further evaluation and treatment. A review of Resident 70's Progress Notes dated 10/30/2023, indicated the resident was transferred to general acute care hospital (GACH) due to fracture of the 9th left rib. During a concurrent interview and record review on 11/1/2023 at 3:50 p.m., with Registered Nurse 3 (RN 3), Resident 70's medical record was reviewed. RN 3 stated he was unable to provide documented evidence of the notice of bed hold policy provided to the resident. RN 3 stated the licensed nurse should have provided the resident or the resident's representative the notice at the time of transfer of the resident to GACH. During an interview on 11/3/2023 at 9:59 a.m., with the Director of Nursing (DON), the DON stated per facility policy, a written bed hold notification should have been provided to the resident or the resident's representative responsible party upon transfer to GACH to make them (resident and the resident's representative) aware that the bed would still be available upon the resident's return to the facility within seven days. A review of the facility's policy and procedure titled, Bed-Holds and Returns, last reviewed on 3/9/2023, indicated all residents/representatives are provided written information regarding the facility and state bed-hold policies which holds or reserves a resident's bed during periods of absence (hospitalization of therapeutic leave) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 11 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 20's admission Record indicated the facility admitted the resident on 10/29/2015, with diagnosis including chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems) with acute exacerbation (the process of making something that is already bad even worse), schizoaffective disorder (a mental illness that affects thoughts, mood, and behavior) and vascular dementia (a type of dementia that occurs when there is damage to the blood vessels in the brain, leading to problems with cognition and memory). A review of Resident 20's History and Physical, dated 4/5/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/13/2023, indicated the resident understood others and able to make self-understood. The MDS indicated the resident required setup assistance with eating and upper body dressing, and required supervision assistance with oral hygiene, toileting hygiene, lower body dressing, personal hygiene, and putting on/taking off footwear. A review of Resident 20's Physician Order, dated 9/16/2022, indicated annual EKG in September 2023, for Zyprexa (an antipsychotic medication that affects chemicals in the brain). During a concurrent interview and record review on 11/3/2023 at 8:23 a.m. with Registered Nurse 2 (RN 2), Resident 20's Progress Notes, dated 10/4/2023 at 3:30 p.m., and care plans were reviewed. RN 2 stated the resident refused EKG three times. RN 2 stated there was no care plan developed for the resident's refusal of the EKG. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, reviewed 3/9/2023, indicated that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The procedure indicated care pan goals and objectives are defined as the desired outcome for a specific resident problem. Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for three out of 31 sampled residents (Residents 80, 93, 34, and 20) by failing to ensure: 1. Resident 80 had a care plan addressing the use of an anticoagulant (Eliquis, a drug to treat and prevent dangerous blood clots). 2. Resident 93 had a care plan addressing the resident's discharge to home. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 12 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Resident 34 had a care plan addressing the use of an anticoagulant (Xarelto, anticoagulant [blood thinner medication] used to lower the risk of stroke [occurs when something blocks blood supply to part of the brain) 4. Residents Affected - Some Resident 20's echocardiogram (EKG, a noninvasive test that records the electrical signal from the heart to check for different heart conditions) was done per physician's order. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 80's admission Record indicated the facility admitted Resident 80 on 2/25/2023, with diagnoses including transient ischemic attack (TIA, a temporary disruption in the blood supply to the brain), cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), and peripheral vascular disease (an accumulation of plaque [fats and cholesterol] in the arteries in the legs or arms). A review of Resident 80's History and Physical (H&P), dated 2/28/2023, indicated Resident 80 had fluctuating capacity to understand and make decisions. A review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/25/2023, indicated Resident 80 had the ability to make self-understood and understand others. The MDS indicated Resident 80 was receiving an anticoagulant (a medication used to prevent the formation of blood clots). A review of Resident 80's Order Summary Report indicated the following orders: -Anticoagulant/hemolytic meds monitoring- Monitor every (q) shift for hematuria (blood in the urine), black tarry stools, coffee-ground emesis (the act of vomiting), sudden severe headache, nausea and vomiting (N&V), lethargy (lack of energy), bruising, sudden changes in mental status, and or vital signs (v/s, essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure), shortness of breath (SOB), nose bleeds, unusual skin discolorations every shift on 3/22/2023. -Eliquis oral tablet (Apixaban). Give 2.5 milligrams (mg, a unit of mas or weight) by mouth two times a day for deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein) on 2/25/2023. During a concurrent interview and record review on 11/1/2023, at 8:19 a.m., with the Director of Staff Development (DSD), Resident 80's care plan was reviewed. The DSD stated there was no care plan for the use of Eliquis. The DSD stated the care plan guides the staff on how to take care of the residents safely. During an interview on 11/3/2023, at 3:40 p.m., with the pharmacist (PHARM), the PHARM stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 13 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 use of the anticoagulant medication should be care planned. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 93's admission Record indicated the facility admitted Resident 93 on 9/8/2023, with diagnoses including legal blindness (visual impairment), sensorineural hearing loss (damage to the inner ear), and history of falling. Residents Affected - Some A review of Resident 93's MDS, dated [DATE], indicated Resident 93 had the ability to make self-understood and understand others. The MDS indicated the Resident 93 had severely impaired cognitive impairment (trouble remembering, learning new whings, concentrating, or making decisions that affect everyday life). The MDS indicated Resident 93 participated in the assessment and goal setting. A review of Physician's Orders, dated 10/3/2023, indicated may discharge home . on October 5, 2023, after he returns from 2:30 p.m. appointment at general acute care hospital 1 (GACH 1) with 2 weeks supply of medication. During a concurrent interview and record review on 11/3/2023, at 1:30 p.m., with the DSD, Resident 93's care plan was reviewed. The DSD stated Resident 93 did not have a discharge care plan. The DSD stated the care plan for discharge was important to ensure safety and readiness of Resident 93's discharge from the facility. A review of the facility's recent policy and procedure titled Discharge Planning, last reviewed on 3/9/2023, corroborateA review of Physician's Orders, dated 10/3/2023, indicated may discharge home . on d with the DSD on 11/2/2023, at 1 p.m., indicated establishment of discharge plans and post discharge care prior to enhance continuity of resident care. It is the policy of this facility to provide ongoing evaluation and discharge planning for all residents while in the facility. Document status in discharge planning section of Care Plan. A review of the facility's recent policy and procedure titled, Care Planning- Interdisciplinary Team, last reviewed on 3/9/2023, indicated the care planning/Interdisciplinary Team shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven (7) days of the resident assessment (MDS). A review of the facility's recent policy and procedure titled, Care Plans- Comprehensive, last reviewed on 3/9/2023, indicated the resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. 3. A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 9/3/2015 and readmitted the resident on 4/1/2021 with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels that supply blood to the brain), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). A review of Resident 34's History and Physical (H&P), dated 5/3/2023, indicated Resident 34 did not have the capacity to understand and make decisions. A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care screening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 14 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tool), dated 9/27/2023, indicated Resident 34 required one-to-two-person physical assistance with bed mobility, transfer, dressing, eating, toileting, and personal hygiene. A review of Resident 34's Order Summary Report indicated the following orders: - Xarelto 20 milligrams (mg - a unit of mass or weight) 1 tablet by mouth in the evening for deep vein thrombosis (DVT- a blood clot in a deep part of the leg) -Anticoagulants medication monitoring for hematuria, black tarry stools, coffee-ground emesis, sudden headache, nausea, vomiting, lethargy, bruising, sudden changes in mentals During a concurrent interview and record review on 10/2/2023, at 12:05 p.m., with Registered Nurse 4 (RN 4), Resident 34's care plan and physician orders were reviewed. RN 4 stated Resident 34 was receiving Xarelto (anticoagulant medication). RN 4 stated that the resident did not have a care plan for the use of Xarelto. RN 4 stated that it was important to have a care plan for the use of Xarelto to ensure the staff know what adverse side effects to monitor. During a concurrent interview and record review on 10/3/2023, at 10:55 a.m., with Registered Nurse 2 (RN 2), Resident 34's care plan and physician orders were reviewed. RN 2 stated Resident 34 is receiving Xarelto. RN 2 stated Resident 34 did not have a care plan for the use of Xarelto. RN 2 stated care plans are important for the resident's optimal well-being. During an interview on 1/3/2023, at 3:03pm., with the Director of Nursing (DON), the DON stated that the facility should create care plans for residents who are on anticoagulant medications. The DON stated that care plans are developed in order to evaluate if the implemented interventions are effective. A review of the facility's policy and procedure titled Care Plans - Comprehensive, last reviewed on 3/2023, indicated, A comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, psychosocial needs shall be developed for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 15 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility licensed nursing staff failed to provide care in accordance with professional standards to one out of twenty-four sampled residents (Residents 71) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Resident 71. Residents Affected - Some This deficient practice had the potential to place the resident at increased risk of developing lipodystrophy (a group of conditions characterized by a complete or partial loss of fat tissue) and amyloidosis (when an abnormal protein called amyloid builds up in the tissues and organs). Findings: A review of Resident 71's admission Record indicated the facility admitted Resident 71 on 9/15/2020 and the facility readmitted Resident 71 on 1/8/2021, with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic neuropathy (nerve damage cause by diabetes) and type 2 diabetes mellitus with diabetic retinopathy (an eye condition that can cause vision loss and blindness in people with diabetes). A review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/5/2023, indicated Resident 71 had the ability to make self-understood and understand others. The MDS indicated the resident was receiving insulin injections. A review of Resident 71's Order Summary Report, indicated the following orders: -Insulin glargine solution 100 units per milliliter (unit/ml, concentration of insulin per milliliter of solution). Inject 27 units subcutaneously one time a day for diabetes mellitus (DM) on 9/12/2023. -Insulin glargine solution. Inject 42 units subcutaneously at bedtime related to type 1 diabetes mellitus without complications on 9/12/2023. -Novolog solution (Insulin Aspart). Inject 5 unit subcutaneously three times a day for diabetes. Only give if eating meal on 8/9/2023. -Novolog solution (Insulin Aspart). Inject as pers sliding scale: if 70-150= none. Give oral gel for blood sugar (B.S.) less than (<) 70 and call MD, if unconscious, give glucagon 1 milligram (mg, a unit of weight) intramuscular (IM, within or into the muscle) then call MD; 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units; 401+ = 12 and call MD, subcutaneously before meals and at bedtime for diabetes. If BS <70 glucogel (a fast-acting dextrose gel that gives an instant sugar boost) 1 tube, 8 ounces (oz, a unit of weight) orange juice (OJ) or light snack if resident alert and able to take orally, if altered level of consciousness (ALOC) give glucagon 1 ampule (amp, a small glass vessel used to hold a solution) IM recheck B.S. and call MD on 8/9/2023.A review of Resident 71's Location of Administration for Insulin from 8/2023 to 11/1/2023 indicated: 8/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 16 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Insulin Glargine Solution Level of Harm - Minimal harm or potential for actual harm 8/3/2023 at 8:08 p.m. at the Abdomen-LLQ 8/5/2023 at 8:53 p.m. at the Abdomen- left lower quadrant (LLQ) Residents Affected - Some 8/11/2023 at 8:50 a.m. at the Abdomen-LLQ 8/12/2023 at 11:20 a.m. at the Abdomen-LLQ 8/17/2023 at 9:10 a.m. at the Abdomen-right upper quadrant (RUQ) 8/18/2023 at 8:19 a.m. at the Abdomen-RUQ 8/23/2023 at 8:59 a.m. at the Arm-left 8/24/2023 at 9:30 a.m. at the Arm-left 8/25/2023 at 10:47 a.m. at the Arm-left 8/27/2023 at 8:59 a.m. at the Abdomen-right lower quadrant (RLQ) 8/28/2023 at 10:44 a.m. at the Abdomen-RLQ Novolog Solution 8/4/2023 at 11:20 a.m. at the Abdomen- left upper quadrant (LUQ) 8/4/2023 at 4:36 p.m. at the Abdomen-LUQ 8/7/2023 at 8:41 p.m. at the Abdomen-RLQ 8/8/2023 at 6:52 a.m. at the Abdomen-RLQ 8/11/2023 at 9:53 p.m. at the Abdomen-RLQ 8/12/2023 at 6:54 a.m. at the Abdomen-RLQ 8/15/2023 at 6:31 p.m. at the Abdomen-RLQ 8/16/2023 at 5:59 a.m. at the Abdomen-RLQ 8/19/2023 at 4:58 p.m. at the Arm-left 8/19/2023 at 9:04 p.m. at the Arm-left 8/21/2023 at 5:04 p.m. at the Abdomen-RUQ 8/22/2023 at 7:04 a.m. at the Abdomen-RUQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 17 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 8/27/2023 at 9:42 p.m. at the Abdomen-RLQ Level of Harm - Minimal harm or potential for actual harm 8/28/2023 at 6:54 a.m. at the Abdomen-RLQ 9/2023 Residents Affected - Some Insulin Glargine Solution 9/6/2023 at 10:44 a.m. at the Abdomen-RUQ 9/7/2023 at 8:24 a.m. at the Abdomen-RUQ 9/9/2023 at 9:19 a.m. at the Abdomen-LLQ 9/10/2023 at 9:28 a.m. at the Abdomen-LLQ 9/16/2023 at 8:37 p.m. at the Abdomen-LUQ 9/17/2023 at 8:35 p.m. at the Abdomen-LUQ 9/18/2023 at 9:41 a.m. at the Arm-right 9/19/2023 at 10:19 a.m. at the Arm-right 9/23/2023 at 9 p.m. at the Abdomen-RUQ 9/24/2023 at 8:22 p.m. at the Abdomen-RUQ 9/25/2023 at 9:23 a.m. at the Abdomen-LLQ 9/26/2023 at 10:40 a.m. at the Abdomen-LLQ Novolog Solution 9/30/2023 at 5:49 p.m. at the Abdomen-LUQ 9/30/2023 at 9:37 p.m. at the Abdomen-LUQ 10/2023 to 11/1/2023 Insulin Glargine Solution 10/1/2023 at 8:37 a.m. at the Abdomen-LLQ 10/2/2023 at 10 a.m. at the Abdomen-LLQ 10/22/2023 at 8:19 a.m. at the Abdomen-RLQ 10/23/2023 at 10:39 a.m. at the Abdomen-RLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 18 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 10/24/2023 at 11:10 a.m. at the Abdomen-RUQ Level of Harm - Minimal harm or potential for actual harm 10/25/2023 at 8:56 a.m. at the Abdomen-RUQ 11/1/2023 at 8:14 p.m. at the Abdomen-LLQ Residents Affected - Some 11/1/2023 at 8:42 a.m. at the Abdomen-LLQ Novolog Solution 10/29/2023 at 8:57 p.m. at the Abdomen-RLQ 10/30/2023 at 6:50 a.m. at the Abdomen-RLQ 10/31/2023 at 6:30 a.m. at the Abdomen-RUQ 10/31/2023 at 4:30 p.m. at the Abdomen-RUQ During a concurrent interview and record review on 11/3/2023, at 9:32 a.m., with Registered Nurse 2, Resident 71's Location of Administration of insulin was reviewed. RN 2 stated there were repeated administration of insulin on the same site from 8/2023 to 11/1/2023. RN 2 stated licensed nurse must change administration sites to prevent bruising, discoloration, and lipodystrophy. During an interview on 11/3/2023, at 10:31 a.m., with the Director of Nursing (DON), the DON stated insulin administration sites should be rotated to prevent lipodystrophy. During an interview on 11/30/2023, at 3:40 p.m., with the Pharmacist (PHARM), the Pharm stated insulin administration sites should be rotated on the following sites: outer arm, outer legs and thigh, and the abdominal areas to prevent blood clot at the site of administration. A review of the copy of Physician's Desk Reference (PDR, a thick volume that provides a guide to prescription drugs available in the United States) Nurse's Drug Handbook, no date, provided by the facility, indicated Lantus administration should alternate injection sites (upper arm, thigh, abdomen). A review of the copy of PDR Nurse's Drug Handbook, no date, provided by the facility, indicated to watch for adverse reactions: Hypoglycemia, hypokalemia, lipodystrophy, hypersensitivity reaction, injection site reactions, pruritus, rash. A review of the Manufacturer's Recommendation of Use for Humulin N KwikPen, US License Number 1891, manufactured by [NAME] Lily and Company, Indianapolis, IN 46285, USA, corroborated with the PHARM on 11/3/2023, at 3:40 p.m., indicated to change (rotate) your injection sites within the area you choose for each dose to reduce risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 19 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of one sampled resident (Resident 77) by failing to ensure Resident 77's bilateral heel protectors were placed on the resident's heels as ordered. Residents Affected - Few This deficient practice had the potential for development and worsening of pressure ulcer/injuries to the resident. Findings: A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023, with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and non-pressure chronic ulcer of right heel and midfoot limited to skin breakdown. A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 77's Order Summary Report, dated 8/7/2023, indicated an order to apply heel protectors to bilateral heel every shift for skin integrity management every shift. A review of Resident 77's Certified Nursing Assistant (CNA) Documentation Survey Report (tasks only) for 10/2023, indicated on 10/31/2023 7 a.m. to 3 p.m. shift, the resident required moderate assistance with lying to sitting on side of bed, rolling left and right, sit to lying, and dependent with personal hygiene and toileting hygiene. During an observation on 10/31/2023 at 8:58 a.m., observed Resident 77 lying in bed with no heel protectors on. During an observation on 11/2/2023 at 9:06 a.m., observed Resident 77 lying in bed with no heel protectors on. During an observation on 11/2/2023 at 10:23 a.m., observed Resident lying in bed with no heel protectors on. During a concurrent observation and interview on 11/2/2023 at 10:40 a.m., with Nurse Aide 1 (NA 1), observed Resident 77 lying in bed. Nurse Aide 1 (NA 1) stated she does not know where the resident's heel protectors are. NA 1 stated the resident did not have heel protectors on when she started her shift. During an observation of the resident's closet, observed the resident's heel protectors inside the closet. NA 1 stated she did not place the heel protectors in the closet. During a concurrent observation and interview on 11/3/2023 at 8:40 a.m., with Registered Nurse 5 (RN 5), in Resident 77's room, observed resident in the wheelchair wearing heel protectors. RN 5 stated the resident is supposed to wear the heel protectors while in bed unless the resident's family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 20 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete requested for the resident to wear the heel protectors while the resident is up on the wheelchair. RN 5 stated it is the facility's to use the heel protectors while the resident is in bed to offload (minimizing or removing weight placed on the foot to help prevent and heal ulcers) the resident's pressure points on the heels. RN 5 stated there is a risk of skin breakdown when the resident is not wearing it. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, reviewed 3/9/2023, indicated that the purpose of this procedure is to provide information regarding identification of pressure injury (ulcer) risk factors and the interventions for specific risk factors. The procedure indicated the support surfaces and pressure redistribution with selected appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice. Event ID: Facility ID: 055002 If continuation sheet Page 21 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and non-pressure chronic ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right heel and midfoot limited to skin breakdown. A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 77's Order Summary Report, dated 8/20/2023, indicated the resident may have floor mats at the side of the bed. A review of Resident 77's care plan titled, Risk for falls, initiated date 5/15/2023, indicated the resident with goals of free of falls and interventions of maintaining a safe environment with floor mats if ordered. A review of Resident 77's Fall Risk Evaluation, dated 9/4/2023, indicated a score of 11, indicating the resident was at risk for falls. The evaluation indicated the resident had poor vision and the resident was not able to perform standing on both feet without holding onto anything, walk straight forward, walk through a doorway, and make a turn. A review of Resident 77's MDS, dated [DATE], indicated the resident understood others and made self-understood. The MDS indicated the resident had a recent fall with no injury. A review of Resident 77's Interdisciplinary Note, dated 10/11/2023 at 1:39 p.m., indicated the weekly fall meeting or 90-day fall review discussed the fall incident on 8/20/2023 on 7 a.m. to 3 p.m. shift with interventions in place, floor mats on both sides of the bed. During observations on 10/31/2023 at 8:58 a.m., and on 11/12/2023 at 9:06 a.m., and at 10:23 a.m., Resident 77 was observed lying in bed with no floor mats placed at the side of the resident's bed. During a concurrent observation and interview on 11/3/2023 at 8:41 a.m., with Certified Nursing Assistant 10 (CNA 10), inside Resident 77's room. Observed Resident 77 sitting up in wheelchair. CNA 10 stated the resident has one floor mat that she folded and placed by the window. CNA 10 stated the floor mat should be in place at the resident's left side for the resident's safety. During an interview on 11/3/2023 at 4:05 p.m., with the Director of Nursing (DON), the DON stated residents at risk for falls have a care plan with interventions including floor mats at side of the bed for the residents' safety. The DON stated the floor mats should be in place because residents may fall and result injury. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, reviewed 3/9/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 22 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some falling and to try to minimize complications from falling. The procedure indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 4. A review of Resident 55's Face Sheet indicated the facility admitted the resident on 5/16/2022 with diagnoses including vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 55's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/27/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and locomotion in the unit, extensive assistance from staff with bed mobility, personal hygiene, and dressing, and totally dependent to staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 55's Smoking Safety Evaluation dated 5/16/2022, 8/19/2022, 11/17/2022, 2/15/2023, 5/16/2023, 8/16/2023, indicated the resident required smoking apron and supervision when smoking for safety. A review of Resident 55's care plan on smoking initiated 5/25/2022 with target date 2/8/2024, indicated a goal that resident will not suffer injury from unsafe smoking practices thru the review date. The policy indicated the following interventions: 1. Resident 55 requires supervision while smoking. 2. Staff will continue to offer/provide a smoking apron while smoking to minimize risk of injury while smoking. During an observation on 11/1/2023 at 1:45 p.m., observed Resident 55 sitting in the wheelchair smoking without an apron. When asked, Resident 55 stated the staff usually offer aprons but unsure why it was not offered today prior to smoking. Resident 55 stated he knew he needed it for safety to prevent cigarette burns. During an interview on 11/1/2023 at 1:47 p.m., with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated that she was just assisting to supervise the residents while smoking. CNA 9 stated she was unsure why the residents were not wearing the smoking aprons. CNA 9 stated the residents should have been wearing the smoking aprons to prevent injuries such as cigarette burns. During an interview on 11/1/2023 at 1:47 p.m., with Activity Assistant 1 (AA 1), AA 1 stated the residents should have been offered the apron and before handing out the cigarettes. During an interview on 11/1/2023 at 2:41 p.m., with the Activity Director (AD), the AD stated all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 23 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents should be offered the smoking aprons prior to smoking. AD stated the residents were supervised by an activity staff and CNAs and failure to offer the smoking aprons prior to smoking can cause harm to the residents. During an interview on 11/1/2023 at 2:51 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs have assigned residents to supervise during smoke breaks. The DSD stated the CNAs should have offered the apron to the residents before the smoking break started. During an interview on 11/3/2023 at 9:55 a.m., with the Director of Nursing (DON), the DON stated smoking breaks are supervised by the activity department staff and CNAs. The DON stated smoking aprons should have been offered or provided to the residents prior to start of smoking breaks because it placed the residents at risk for injuries such as cigarette burns. The DON stated, if the residents refused, the licensed nurse (LN) should have been notified of the refusal so the LN can offer the apron again to the residents. The DON stated if the resident continues to refuse, the LN will document in the care plan. A review of the facility's policy and procedure titled, Smoking Policy and Procedures, last reviewed 3/9/2023, indicated the residents will be provided with smoking aprons, as necessary. Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and implemented measures to prevent accidents for five of five sampled residents, by failing to: 1. Ensure smoking aprons were provided or offered to four of four sampled residents (Resident 7, 29 36, 55). This deficient practice had the potential for placing the residents at risk for sustaining injuries related to cigarette burns. 2. Ensure bilateral floor mats (high-impact foam and are designed to help prevent injury from potential falls) were provided for Resident 77 as ordered by the physician. This deficient practice had the potential to result in fall related injuries. Findings: 1. A review of Resident 36's admission Record indicated the facility admitted the resident on 9/13/2021, with diagnoses including schizoaffective disorder, depressive type (a mental health disorder with symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 36's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 36 had the ability to make self-understood and understand others. A review of Resident 36's Smoking Safety Evaluation, date 9/8/2023, indicated apron as a safety requirement during smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 24 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 11/1/2023 at 1:47 p.m., with Certified Nursing Assistant 4 (CNA 4), observed Resident 36 smoking on the patio without a smoking apron. Certified Nursing Assistant 4 (CNA 4) stated she was only helping the Activities Assistant supervise the smoking area and was not sure why the resident was not wearing a smoking apron. During an interview on 11/1/2023 at 1:47 p.m., Activities Assistant (AA 2), AA 2 stated he had not given out the aprons because he was passing out cigarettes and lighting the cigarettes for the residents. AA2 stated the aprons should have been offered to the residents prior to lighting the cigarettes. AA 2 stated the aprons should have been offered to the residents for safety. During an interview on 11/1/2023 at 2:41 pm., with the Activities Director (AD), the AD stated the staff supervising the smoking patio should make sure ashtrays and aprons are always present, so the residents do not burn themselves. During an interview on 11/1/2023 at 2:51 p.m., with the Director of Staff Development (DSD), the DSD stated the staff supervising the smoking patio should provide residents with aprons and ashtrays. A review of the facilities recent Policies and Procedures(P&P) titled, Country Manor Healthcare Smoking Policy and Procedure-Residents, last revised on 3/9/2023, indicated Residents will be provided with smoking apron as necessary. 2. A review of Resident 7's admission Records indicated the facility admitted Resident 7 on 8/28/1995 and readmitted the resident on 03/31/2023, with diagnoses including achalasia cardia (a rare swallowing disorder), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and deaf nonspeaking (deaf people who cannot speak on oral language). A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 7 had mild cognitive impairment (when someone has symptoms showing changes in their memory or their thinking, but the changes do not affect their ability to do day to day activities). The MDS indicated that Resident 7 required maximal assistance from staff with toileting, dressing, showering, and personal hygiene. MDS also indicated that Resident 7 required supervision while eating and used a wheelchair as a mobility device. A review of Resident 7's care plan, dated 2/16/2018, indicated that the resident was at high risk for injury related to smoking and required an apron during supervised smoke breaks to minimize the risk of smoking burns. A review of Resident 7's Smoking Safety evaluation, dated 10/16/23, indicated to use a smoking apron while smoking as a safety requirement. 3. A review of Resident 29's admission Records indicated the facility admitted Resident 29 on 4/1/2019 and readmitted him on 5/7/2021 with diagnoses including bipolar type of schizoaffective disorder (a serious mental illness that affects that affects how a person thinks, feels, and behaves) and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 25 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tool), dated 2/8/2023, indicated Resident 29 had mild cognitive impairment (when someone has symptoms showing changes in their memory or their thinking, but changes do not affect their ability to do day -to day activities). The MDS indicated Resident 29 required one person assistance from staff with toileting, dressing, showering, and personal hygiene. The MDS also indicated that Resident 29 required supervision while eating and used a wheelchair as a mobility device. A review of Resident 29's care plan, dated 5/10/2021, indicated that the resident was at high risk for injury related to smoking and required an apron during supervised smoke breaks to minimize the risk of smoking burns. During a concurrent observation and interview on 11/1/2023 at 1:47 p.m., with Certified Nursing Assistant (CNA 4), observed Resident 7 and Resident 29 were observed not wearing smoking aprons while smoking on the patio. Certified Nursing Assistant 4 (CNA 4) stated she was only helping the Activities Assistant (AA) supervise the smoking area and was not sure why the residents were not wearing smoking aprons. During an observation and interview on 11/3/2023 at 1:55 p.m., Resident 29 was observed not wearing a smoking apron while smoking on the patio. Resident 29 stated, I would love to wear a smoking apron if someone offered it to me. During an interview on 11/1/2023 at 2:41 p.m., with the Activity Director (AD), the AD stated that an apron should be offered to residents before they smoke for the residents' safety. During an interview on 11/1/2023 at 2:51 p.m., the Director of Staff Development (DSD) stated that all Certified Nursing Assistants (CNAs) have assigned residents to supervise during smoking breaks. The DSD stated that CNAs should provide residents with an apron before they start smoking. During an interview on 1/3/2023 at 3:03 p.m., with the Director of Nursing (DON), the DON stated that if residents are not wearing an apron during smoking it puts the residents at risk for injury and burns. A review of the facility's policy titled Country Manor Healthcare Smoking Policy and Procedure-Residents, last revised on 3/9/2023, indicated that residents will be provided with smoking aprons as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 26 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to provide catheter care (reduces the risk of complications such as infections) in a manner to prevent odors, and infection for one of one sampled resident (Resident 77) investigated under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) or urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra) care area. This deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder). Cross reference to F726 and F728. Findings: A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and encounter for surgical aftercare following surgery on the genitourinary system (organs of the reproductive system and the urinary system). A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/4/2023, indicated the resident understood others and made self-understood. The MDS indicated the resident had an indwelling catheter (urinary catheter). A review of Resident 77's Order Summary Report, dated 8/20/2023, indicated the order for indwelling catheter for diagnosis urinary retention. A review of Resident 77's care plan titled, Requires assistance with Activities of Daily Living (ADL, describe fundamental skills required to independently care for oneself), initiated date of 5/15/2023, indicated the goals of meeting the resident's needs. The care plan interventions indicated the resident required up to extensive assistance by Certified Nursing Assistant (CNA) with personal hygiene and oral care, toilet use, and physical assistance by CNA with bathing/showering and as necessary. A review of Resident 77's Certified Nursing Assistant (CNA) Documentation Survey Report (tasks only) 10/2023, indicated on 10/31/2023 7 a.m. to 3 p.m. shift, the resident required moderate assistance with lying to sitting on side of bed, rolling left and right, sit to lying, and dependent with personal hygiene and toileting hygiene. During a concurrent observation and record review on 11/2/2023 at 10:40 a.m., with Nurse Assistant 1 (NA 1) at Resident 77's bedside, observed Resident 77 lying in bed wearing a hospital gown. Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 27 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Aide 1 (NA 1) stated she will give care to the resident and have the resident ready for the day. Observed NA 1 at Resident 77's left side with gloves on. NA 1 stated CNA 2 will assist her in turning the resident. CNA 2 provided privacy by drawing the curtains fully closed. CNA 2 took two (2) dry wash cloths to the toilet sink. CNA 2 stated he soaked the washcloths in warm water. CNA 2 folded the two soaked washcloths into one bundle. Observed NA 1 provide catheter care to Resident 77. CNA 2 handed two wash cloths soaked in warm water from the toilet sink. CNA 2 was standing at Resident 77's right side with gloves on and removed the fasteners/tape off the resident's briefs. Observed the urinary catheter tubing connected to Resident 77 and draining clear, yellow urine. NA 1 used the bundled washcloth to clean the resident's left groin, right groin, and on top surface of the resident's genital area with a total of three wipes. NA 1 was not observed cleaning the area at the resident's catheter insertion and did not observe the resident was dried after the wash cloths were used. NA 1 and CNA 2 repositioned the resident to his right side to clean his backside. NA 1 used cleaning wipes to clean the resident's back area. NA 1 placed clean briefs on Resident 77. On 11/2/2023 at 10:52 a.m., observed CNA 2 empty Resident 77's urinary drainage bag. CNA 2 stated there is 320 millimeters (unit of measurement) of urine inside. CNA 2 removed gloves, performed hand hygiene, and put on new gloves. NA 1 and CNA 2 put on resident's long-sleeve shirt and pants. On 11/2/2023 at 11:02 a.m., NA 1 and CNA 2 transferred Resident 77 on his wheelchair. NA 1 stated she is done providing peri-care to the resident. During an interview on 11/2/2023 at 11:20 a.m., with CNA 2, CNA 2 stated he was helping NA 1 with providing care to Resident 77 because the resident is totally dependent. CNA 2 stated they are supposed to clean the resident's catheter insertion area but did not observe NA 1 do it. CNA 2 stated NA 1 did not dry the resident after providing perineal care. During an interview on 11/2/2023 at 11:33 a.m., CNA 2 stated it is important to clean the resident's perineal area well and gently because the resident's skin is sensitive and fragile which can result in infection or skin tears and sores. During an interview on 11/2/2023 at 1:35 p.m., with NA 1, NA 1 stated this is the first-time she provided care to Resident 77. NA 1 stated she is supposed to clean the catheter insertion area. NA 1 stated she thought CNA 2 cleaned the resident's catheter insertion area. NA 1 stated she does not remember if she did it. During an interview on 11/3/2023 at 3:20 p.m., with Registered Nurse 2 (RN 2), RN 2 stated it is important that licensed nurses and CNAs provide catheter care well to the residents to prevent infections. A review of the facility's policy and procedure titled, Catheter Care, Indwelling Catheter, reviewed 3/9/2023, indicated the purpose of this procedure is to prevent infection and reduce irritation. The procedure indicated the following: 1. Position resident in semi-Fowler's position on bed pan if tolerated or use alternate position. 2. Put on gloves. 3. Pour warm water over perineal area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 28 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 4. Wash perineum well with soap and warm water, taking care to wash from front to back. Level of Harm - Minimal harm or potential for actual harm 5. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. 6. All debris must be removed from catheter at insertion site. Residents Affected - Few 7. Rinse well with warm water and pat dry gently with clean towel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 29 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice to one of twenty-four sampled residents (Resident 41) by failing to ensure: Residents Affected - Few 1. The nasal prongs of the nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) were inserted on both nostrils of Resident 41. The deficient practice had the potential for Resident 41 not to get enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body). 2. The nasal cannula tubing was labeled with the date it was last changed. The deficient practice had the potential for Resident 41's nasal cannula tubing to grow bacteria that could cause respiratory infections. Findings: A review of Resident 41's admission Record indicated the facility admitted Resident 41 on 8/13/2015 and readmitted Resident 41 on 8/26/2023, with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypercapnia (a buildup of carbon dioxide in the body), acute pulmonary edema (a buildup of fluid in the lungs), and dependence on supplemental oxygen. A review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/6/2023, indicated Resident 41 had the ability to make self-understood and understand others. The MDS indicated Resident 41 was on oxygen therapy (a treatment that provides extra oxygen to breathe). A review of Resident 41's Order Summary Report, dated 8/26/2023, indicated an order to administer oxygen at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula/mask to maintain oxygen (O2) saturation (a measurement of how much oxygen in the blood is carrying a percentage of the maximum it could carry) greater than ( > ) 92% every shift for low O2 saturation and to change and label oxygen cannula, oxygen tubing, humidifier (medical device to humidify supplemental oxygen), and bag weekly on Saturdays 11-7 shift every night shift every Sat. A review of Resident 41's Care Plan indicated Resident 41 has a care plan addressing oxygen therapy, if necessary (PRN) related to (r/t) episode of low O2 saturation after hemodialysis (a treatment to filter wastes and water from the blood), initiated on 8/12/2022. During a concurrent observation and interview on 10/31/2023, at 10:14 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 41's nasal cannula prong not inserted on both nostrils of the resident and the oxygen tubing was not labeled with the date it was last changed. LVN 2 stated the nasal cannula prong should be inserted on both resident's nostrils to get the right amount of oxygen in the body. LVN 2 stated the incorrect placement of the nasal cannula to the resident's nose could lead to shortness of breath and hypoxia to resident. LVN 2 also stated the oxygen tubing was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 30 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few labeled with the date it was last changed. LVN 2 stated the failure to date the tubing could lead to infection because you do not know when it was last changed. During an interview on 11/2/2023, at 1:33 p.m., with the Director of Staff Development (DSD), the DSD stated the resident was not receiving proper dosage of oxygen due to the improper placement of the nasal cannula on the resident that could lead to shortness of breath. The DSD stated the oxygen tubing should be labeled with the date it was last changed for infection control. The DSD stated after the oxygen tubing sat for a long time, it could grow bacteria in the tubing that resident can breathe in. The DSD stated labeling the oxygen tubing helps to know when to replace it. During an interview on 11/3/2023, at 10:31 a.m., with the Director of Nursing (DON), the DON stated the nasal cannula prong should sit on both nostrils of the resident to get the prescribed amount of oxygen to the resident. The DON stated failure of the staff to place the nasal cannula could lead to shortness of breath on the resident. The DON stated the oxygen tubing should be labeled with the date it was last changed so the staff know when to change the tubing and for infection control. A review of the facility's recent policy and procedure titled, Oxygen Equipment, last reviewed on 3/9/2023, corroborated with the DSD on 11/2/2023, at 1 p.m., indicated the facility will use disposable pre-filled humidifiers, tubing, mask, and cannulas for residents receiving oxygen. The equipment is to be discarded after use. Tubing should be replaced every week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 31 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure one of one Nursing Aide (Nursing Aide 1 [NA 1]) was competent to provide indwelling catheter care (reduces the risk of complications such as infections) for one of one sampled resident (Resident 77), who had physician order for indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely). This deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder). Cross reference to F690 and F728. Findings: A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and encounter for surgical aftercare following surgery on the genitourinary system (organs of the reproductive system and the urinary system). A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/4/2023, indicated the resident understood others and made self-understood. The MDS indicated the resident had an indwelling catheter (urinary catheter). A review of Resident 77's Order Summary Report, dated 8/20/2023, indicated an order for indwelling catheter for diagnosis urinary retention. A review of Resident 77's care plan titled, Requires assistance with Activities of Daily Living (ADL, describe fundamental skills required to independently care for oneself), with initiated date of 5/15/2023, indicated the goals of meeting the resident's needs. The care plan interventions indicated the resident required up to extensive assistance by Certified Nursing Assistant (CNA) with personal hygiene and oral care, toilet use, and physical assistance by CNA with bathing/showering and as necessary. A review of Resident 77's Certified Nursing Assistant (CNA) Documentation Survey Report (tasks only) 10/2023, indicated on 10/31/2023 7 a.m. to 3 p.m. shift, the resident required moderate assistance with lying to sitting on side of bed, rolling left and right, sit to lying, and dependent with personal hygiene and toileting hygiene. During a concurrent observation and record review on 11/2/2023 at 10:40 a.m., with Nurse Assistant 1 (NA 1) at Resident 77's bedside, observed Resident 77 lying in bed wearing a hospital gown. Nurse Aide 1 (NA 1) stated she will give care to the resident and have the resident ready for the day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 32 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observed NA 1 at Resident 77's left side with gloves on. NA 1 stated CNA 2 will assist her in turning the resident. CNA 2 provided privacy by drawing the curtains fully closed. CNA 2 took two (2) dry wash cloths to the toilet sink. CNA 2 stated he soaked the washcloths in warm water. CNA 2 folded the two soaked washcloths into one bundle. Observed NA 1 provide catheter care to Resident 77. CNA 2 handed two wash cloths soaked in warm water from the toilet sink. CNA 2 was standing at Resident 77's right side with gloves on and removed the fasteners/tape off the resident's briefs. Observed the urinary catheter tubing connected to Resident 77 and draining clear, yellow urine. NA 1 used the bundled washcloth to clean the resident's left groin, right groin, and on top surface of the resident's genital area with a total of three wipes. NA 1 was not observed cleaning the area at the resident's catheter insertion and did not observe the resident was dried after the wash cloths were used. NA 1 and CNA 2 repositioned the resident to his right side to clean his backside. NA 1 used cleaning wipes to clean the resident's back area. NA 1 placed clean briefs on Resident 77. On 11/2/2023 at 10:52 a.m., observed CNA 2 empty Resident 77's urinary drainage bag. CNA 2 stated there is 320 millimeters (unit of measurement) of urine inside. CNA 2 removed gloves, performed hand hygiene, and put on new gloves. NA 1 and CNA 2 put on resident's long-sleeve shirt and pants. On 11/2/2023 at 11:02 a.m., NA 1 and CNA 2 transferred Resident 77 on his wheelchair. NA 1 stated she is done providing peri-care to the resident. During an interview on 11/2/2023 at 11:20 a.m., with CNA 2, CNA 2 stated he was helping NA 1 with providing care to Resident 77 because the resident is totally dependent. CNA 2 stated they are supposed to clean the resident's catheter insertion area but did not observe NA 1 do it. CNA 2 stated NA 1 did not dry the resident after providing perineal care. During an interview on 11/2/2023 at 11:33 a.m., CNA 2 stated it is important to clean the resident's perineal area well and gently because the resident's skin is sensitive and fragile which can result in infection or skin tears and sores. During an interview on 11/2/2023 at 1:35 p.m., NA 1 stated this is the first-time she provided care to Resident 77. CNA 1 stated she is supposed to clean the catheter insertion area. NA 1 stated she thinks CNA 2 cleaned the resident's catheter insertion area. NA 1 stated she does not remember if she did it. During an interview on 11/3/2023 at 3:20 p.m., Registered Nurse 2 (RN 2) stated it is important that licensed nurses and CNAs provide catheter care well to the residents to prevent infections. A review of the facility's policy and procedure titled, Catheter Care, Indwelling Catheter, reviewed 3/9/2023, indicated the purpose of this procedure is to prevent infection and reduce irritation. The procedure indicated the following: 1. Position resident in semi-Fowler's position on bed pan if tolerated or use alternate position. 2. Put on gloves. 3. Pour warm water over perineal area. 4. Wash perineum well with soap and warm water, taking care to wash from front to back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 33 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 5. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. Level of Harm - Minimal harm or potential for actual harm 6. All debris must be removed from catheter at insertion site. 7. Rinse well with warm water and pat dry gently with clean towel. Residents Affected - Some During an interview and record review on 11/3/2023 at 9:43 a.m., with the Assistant Administrator (AADM), reviewed NA 1's employee file. The AADM stated the facility hired NA 1 on 7/28/2023 as full time CNA. The AADM stated NA 1's certificate number and orientation checklist was not on file. During an interview on 11/3/2023 10:09 a.m., the DSD stated on the first day of the CNA's orientation checklist is completed. The DSD stated once the orientation checklist is completed it will be filed in the employee's file. The DSD stated he does not know why NA 1's orientation checklist was not on her employee file. A review of the facility's policy and procedure titled, Credentialing of Nursing Service Personnel, reviewed 3/9/2023, indicated that a nursing service personnel who require a certification to provide resident care or treatment without direction or supervision within the scope of the individual's certification must present verification of such certification prior to or upon employment. The procedure indicated nursing personnel requiring a certification are not permitted to perform direct resident care services until all licensing/background checks have been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 34 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review, the facility failed to ensure Nurse Aide 1, who was employed as a Certified Nursing Assistant, had successfully completed the state's Certified Nursing Assistant (CNA) competency evaluation examination (a standardized assessment that measures the knowledge and skills of individuals seeking certification as a CNA). The facility failed to provide NA 1's CNA certificate number. This deficient practice had the potential to result in the residents receiving substandard care, leading to potential health risks and complications. Cross reference to F690 and F728. Findings: During an interview and record review on 11/3/2023 at 9:43 a.m., with the Assistant Administrator (AADM), reviewed NA 1's employee file. The AADM stated the facility hired NA 1 on 7/28/2023 as full time CNA. The AADM stated NA 1's certificate number and orientation checklist was not on file. During a concurrent interview and record review on 11/3/2023 at 1:44 p.m., with the Director of Staff Development (DSD), reviewed NA 1's training program certificate. The DSD stated the training program certificate indicated NA 1 completed the training program on 4/9/2021. During an interview on 11/3/2023 at 4:52 p.m., with the DSD, the DSD stated NA 1 an education (training program) certificate but did not have a certificate number to work as a CNA. The DSD stated NA 1 did not complete the CNA state competency evaluation examination. The DSD stated it was an oversight on his part. A review of the facility's policy and procedure titled, Credentialing of Nursing Service Personnel, reviewed 3/9/2023, indicated that a nursing service personnel who require a certification to provide resident care or treatment without direction or supervision within the scope of the individual's certification must present verification of such certification prior to or upon employment. The procedure indicated nursing personnel requiring a certification are not permitted to perform direct resident care services until all licensing/background checks have been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 35 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure one of five sampled residents (Residents 81) reviewed for unnecessary medications was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to provide documented diagnosis for administering Olanzapine (antipsychotic medication, drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) to Resident 81. This deficient practice had the potential to result in ineffective treatment and placed the resident at risk for receiving unnecessary psychotropic medication and adverse effects (unwanted effects that a medication may have) including sedation, fatigue, death typically occurred due to heart failure (a progressive heart disease that affects pumping action of the heart muscles), or sudden death. Findings: A review of Resident 81's admission Record indicated the facility admitted the resident on 2/17/2022, with diagnoses including vascular dementia (a type of dementia that occurs when there is damage to the blood vessels in the brain, leading to problems with cognition and memory), unspecified psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and delusional disorders (type of mental health condition in which a person cannot tell what is real from what is imagined). A review of Resident 81's History and Physical, dated 7/21/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 81's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/17/2023, indicated the resident made self-understood and understood others. The MDS indicated the resident did not have an active diagnosis of schizophrenia in the last seven days. A review of Resident 81's Order Summary Report, dated 9/5/2023, indicated an order for Olanzapine tablet, give 2.5 milligrams (mg, a unit of measure) by mouth at bedtime for schizophrenia (mental disorder in which people interpret reality abnormally) manifested by auditory hallucinations as evidenced by talking to unseen being. During a concurrent interview and record review on 11/2/2023 at 3:23 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 81's physician orders, progress notes, psychiatric progress notes, H & P, and diagnosis list. RN 4 stated the resident has an order for Olanzapine for which the resident was receiving for diagnosis of schizophrenia. Resident 81's Psychiatric Progress Notes dated 8/22/2023, 9/13/2023, and 10/11/2023, H&P, and Diagnosis List did not indicate the resident has a diagnosis of schizophrenia. During a concurrent interview and record review, on 11/3/2023 at 9:53 a.m., reviewed Resident 81's Pharmacy Discharge Note, dated 2/17/2022, with RN 4. RN 4 stated the resident has the following orders for Olanzapine: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 36 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Olanzapine tab 5 mg by mouth (PO) every six hours as needed for mil-moderate agitation, olanzapine not to exceed 40 mg total daily dose. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few Olanzapine tab 5 mg PO at bedtime for thought organization/mood. During a concurrent interview and record review, on 11/3/2023 at 5:12 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure (P&P) titled, Psychoactive Drug Monitoring, The DON stated the use of anti-psychotic medications should include a diagnosis with description of symptoms, discussion of the psychiatrist and medical differential diagnosis to show justification for the continued use. A review of the facility's P&P titled, Psychoactive Drug Monitoring, reviewed 3/9/2023, indicated that it is the facility's policy that every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. The procedure indicated that the resident's physician provides a justification for the continued use of the drug and dosage as clinically appropriate, and this justification appears somewhere in the resident's record. The procedure indicated the justification to include: a. A diagnosis with description of symptoms. b. A discussion of the psychiatrist and medical differential diagnosis (a systematic process used to identify the proper diagnosis from a set of possible competing diagnoses). c. A description of the rationale for the choice of a particular treatment(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 37 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to maintain safe and proper temperatures for all medications for one of two medication room refrigerators (Med Ref 1) by: 1. Failing to ensure the medication refrigerator freezer did not have ice buildup. 2. Failing to ensure the refrigerator temperature was maintained between 36 Fahrenheit (F, a unit of measure) to 46 F. This deficient practice had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful. Cross reference to F908. Findings: During a concurrent observation and interview, in Med Ref 1, on 11/1/2023 at 2:44 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed medication refrigerator with temperature reading at 28 F. LVN 2 stated there is ice buildup inside the fridge and will ask maintenance to clean the refrigerator. LVN 2 stated the medication refrigerator's temperature should be between 36 F to 46 F. During a concurrent observation and interview, inside Med Ref 1, on 11/1/2023 at 3:55 p.m., with the Registered Nurse 1 (RN 1), observed ice buildup inside the medication refrigerator. RN 1 stated the medication refrigerator's temperature reading is at 29 F. RN 1 stated 29 F is below the appropriate temperature for medications that needs refrigeration. RN 1 stated the temperature of the refrigerator should be between 36 F to 46 F because it may affect the medications and render the medications ineffective. RN 1 stated there is a risk for harm to the residents who received ineffective medications. RN 1 stated the medication refrigerator's ice buildup should have been reported it to the maintenance. Observed inside the medication refrigerator the following medications: One insulin (a hormone that lowers the level of sugar in the blood) glargine (a hormone for Resident 48 One Humulin R (an insulin medication) vial for Resident 96 Two (2) insulin aspart injectable pens for Resident 34 Three (3) vials of Tuberculin Purified Protein Derivative, Diluted Aplisol (a sterile aqueous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 38 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]). - Residents Affected - Few One semaglutide (a medication that works by increasing insulin levels in your body, which decreases your blood sugar [glucose]) injectable pen for Resident 296 One Risperdal (an antipsychotic medication that affects chemicals in the brain) injection for Resident 12 During a concurrent interview and record review 1on 11/1/2023 at 4:06 p.m., with RN 1, the maintenance log for Nursing Station 1 was reviewed. RN 1 stated there was no documentation for a request to fix the medication refrigerator inside the medication room for 11/2023. A review of the facility's policy and procedure titled, Medication Storage and Labeling, reviewed 3/9/2023, indicated it is the facility's policy that drugs requiring refrigeration shall be stored in a refrigerator between 36F and 46F. The procedure indicated that drugs shall be stored in appropriate temperatures and drugs requiring refrigeration shall be stored in a refrigerator between 36 F and 46 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 39 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review the facility failed to provide food that accommodates resident preferences for one out of twenty-four sampled residents (Resident 36) by failing to ensure Resident 36's preferences were updated per facility's policy and procedure. The deficient practice had the potential for resident to have poor appetite that could potentially result in weight loss. Findings: A review of Resident 36's admission Record indicated the facility admitted Resident 36 on 9/13/2021, with diagnoses including protein-calorie malnutrition (an imbalance between the nutrients the body needs and the nutrients it gets), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid drained through the body's lymphatic system [part of the immune system]). A review of Resident 36's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/8/2023, indicated Resident 36 had the ability to make self-understood and understand others. A review of Resident 36's Order Summary Report, dated 8/9/2023, indicated an order for NAS (No Added Salt) diet, regular texture, thin/regular liquid consistency, small portions. A review of Resident 36's admission Nutritional Assessment, dated 9/15/2021, indicated Resident 36 was on NAS, regular texture food. The Nutritional Assessment indicated resident liked over easy eggs, regular milk, and mixed vegetables. No food dislikes were indicated on the assessment. A review of Resident 36's Quarterly Nutritional Assessment, dated 9/8/2023, indicated Resident 36 was on NAS diet, regular texture, thin/regular liquid consistency. No indication of food likes and dislikes noted on the assessment note. During an interview on 10/31/2023, at 10:40 a.m., Resident 36 stated she has not seen a dietician for a long time. Resident stated she wanted to update her food preferences. During an interview and record review on 11/2/2023, at 1:59 p.m., with the Registered Dietician (RD), reviewed Resident 36's medical record. The RD stated Resident 36's diet was NAS, regular consistency, and regular texture. The RD stated the resident had her quarterly nutritional assessment on 9/8/2023. The RD stated that the Dietary Supervisor (DS) oversaw the updating of the resident's preferences. The RD stated the DS should have followed up with Resident 36 after her quarterly nutritional assessment to update Resident 36's food preferences. During an interview and record review on 11/3/2023, at 9:28 a.m., with the DS, reviewed Resident 36's medical record. The DS stated the last time she saw the resident was 9/8/2023. The DS stated that she should have updated Resident 36's food preferences during her quarterly nutritional assessment. The DS further stated they should not wait for the quarterly nutritional assessment to update the food preferences of the residents especially if they were losing weight. The DS stated she needed more help in seeing residents more frequently to update resident's food preferences. The DS stated not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 40 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seeing the residents regularly to update food preferences could lead to weight loss due to residents not eating the diet trays served to them. During an interview on 11/3/2023, at 10:31 a.m., the Director of Nursing (DON) stated that the dietary department should have asked the resident for food preferences daily. The DON stated it was important to consider food preferences because sometimes residents refuse the food if they do not like them and if they want the food being served to them, they will eat more, thus improving their nutrition. A review of the facility's policy and procedure titled, Nutritional Screening/Assessments/Resident Care Planning, last reviewed on 3/9/2023, indicated the Food and Nutrition Services (FNS) Director will complete the Dietician Assessment & Monitoring Sheet on a daily basis and give this sheet to the Consultant Dietician on each visit. A review of the facility's recent policy and procedure titled, Food Preferences, last reviewed on 3/9/2023, indicated updating of food preferences will be done as residents' needs change and/or during quarterly review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 41 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow proper sanitation and food handling practices by: 1. Failing to store food in accordance with professional standards for food service safety by failing to discard: A. [NAME] cooking wine, which expired on 7/28/2022 and was observed in the dry storage room on 10/31/2023. B. [NAME] pie shell wrapped in plastic wrap, dated 9/9/2023, with no expiration date, which was observed in the dry storage room. C. Traditional Stuffing mix, with no expiration date, which was observed in the dry storage room on 10/31/2023. D. Thawing ground beef, dated 10/28/2023, which was observed in the refrigerator on 10/31/23. E. Ground beef, dated 10/28/2023, and ground chicken, dated 10/31/2023, thawing in the same pan, which were observed in the refrigerator on 10/31/2023. F. Pancakes, prepared on 10/25/2023, with an expiration date of 10/28/2023, which were observed in the refrigerator on 10/31/2023. G. A box of unopened sliced ham with a sell by date of 9/23/2023, which was observed in the refrigerator on 10/31/2023. H. 12 blocks of margarine with no expiration date, which were observed in the refrigerator on 10/31/2023. 2. Failing to ensure that the dry produce storage room was used for food only. On 10/31/2023, HP cartridges for ink and gloves were observed being stored in the dry produce storage room. Observed on top of the HP cartridges were observed two boxes of a lemonade soft drink mix and one box of fruit mix in pear juice. 3.Failing to ensure that a food thermometer was being used properly by failing to sanitize the thermometer between dishes during the meal tray line on 11/01/2023, at 11:40 a.m. These deficient practices had the potential to result in foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) for residents living in the facility. Findings: During a concurrent observation of the storage room and refrigerator and interview on 10/31/2023, at 8:25 a.m., with the Dietary Supervisor (DS), the DS stated that the white [NAME] cooking wine, pancakes, and sliced ham should have all been discarded before their expiration date. The DS stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 42 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the graham pie shell wrapped in plastic wrap, traditional stuffing mix, and 12 blocks of margarine should have been labeled with the received date, open date, and best by date to ensure that the food items were not expired. The DS stated that the staff should indicate the received date, open date, and best by date for all food products transferred to other containers so the staff know when to discard them. The DS stated that the thawed ground beef should not have been stored in the same container with the ground chicken to prevent cross contamination. The DS stated that according to facility policy, the dry produce storage room should be used for storage of food only, and the HP cartridges for ink and boxes of gloves should have been stored separately from the food supply to prevent cross contamination. During a concurrent observation and interview on 11/1/2023 at 11:40a.m., with the DS, during the food tray line, Dietary [NAME] 1 (DC1) was observed using a digital thermometer to check the temperature of beef cubes with mushroom. DC1 wiped the thermometer with a white paper napkin and used the thermometer to check the temperature of the pasta. DC1 then wiped the thermometer with a white paper napkin again and proceeded to take the temperature of the seasoned spinach with the same thermometer. The DS stated that DC1 used a regular two-ply dinner napkin (DN300-2) to clean the thermometer. DS stated that the dinner napkin (DN300-2) does not contain any sanitizing agent and that these napkins are not supposed to be used for sanitizing the thermometer. The DS stated that DC1 is supposed to use an alcohol swab or a food-grade sanitizer to prevent cross contamination of dishes. During an interview on 11/3/2023 at 3:03 p.m., with the Director of Nursing (DON), the DON stated that the staff should be checking the food items for expiration dates, open dates, and best by dates because expired food products may harm the residents. The DON stated that the kitchen staff should have removed all expired food items and items that were not properly dated and labeled. The DON stated that the dry storage room should be used to store food items only to prevent cross contamination. The DON stated that thermometer should be sanitized between dishes to prevent cross contamination of food allergens. A review of the facility's recent policy and procedure titled, Storage of food and supplies, last reviewed on 3/9/2023, indicated: Food storage areas should be used only for food . All food products will be datedmonth, date, year .Food in unlabeled . containers .not be retained or used. A review of the facility's recent policy and procedure titled, Procedure for refrigerated storage, last reviewed on 3/9/2023, indicated: Individual packages of refrigerated or frozen food taken from original packing box need to be labeled and dated. A review of the facility's recent policy and procedure titled, Thermometer use and calibration, last reviewed on 3/9/2023, indicated: Wipe the clean thermometer with the sanitizing solution using a clean cloth or paper towel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 43 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain one of two medication room refrigerators (Med Ref 1) in safe operating condition by: Residents Affected - Few 1. Failing to ensure the medication refrigerator freezer did not have ice buildup. 2. Failing to ensure the refrigerator temperature was maintained between 36 Fahrenheit (F, a unit of measure) to 46 F. This deficient practice had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful. Cross reference to F761. Findings: During a concurrent observation and interview, in Med Ref 1, on 11/1/2023 at 2:44 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed medication refrigerator with temperature reading at 28 F. LVN 2 stated there is ice buildup inside the fridge and will ask maintenance to clean the refrigerator. LVN 2 stated the medication refrigerator's temperature should be between 36 F to 46 F. During a concurrent observation and interview, inside Med Ref 1, on 11/1/2023 at 3:55 p.m., with the Registered Nurse 1 (RN 1), observed ice buildup inside the medication refrigerator. RN 1 stated the medication refrigerator's temperature reading is at 29 F. RN 1 stated 29 F is below the appropriate temperature for medications that needs refrigeration. RN 1 stated the temperature of the refrigerator should be between 36 F to 46 F because it may affect the medications and render the medications ineffective. RN 1 stated there is a risk for harm to the residents who received ineffective medications. RN 1 stated the medication refrigerator's ice buildup should have been reported it to the maintenance. Observed inside the medication refrigerator the following medications: Observed inside the medication refrigerator the following medications for: One insulin (a hormone that lowers the level of sugar in the blood) glargine (a hormone for Resident 48 One Humulin R (an insulin medication) vial for Resident 96 Two (2) insulin aspart injectable pens for Resident 34 Three (3) vials of Tuberculin Purified Protein Derivative, Diluted Aplisol (a sterile aqueous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 44 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor Healthcare 11723 Fenton Avenue Lake View Terrace, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]). - Residents Affected - Few One semaglutide (a medication that works by increasing insulin levels in your body, which decreases your blood sugar [glucose]) injectable pen for Resident 296 One Risperdal (an antipsychotic medication that affects chemicals in the brain) injection for Resident 12 During a concurrent interview and record review 1on 11/1/2023 at 4:06 p.m., with RN 1, the maintenance log for Nursing Station 1 was reviewed. RN 1 stated there was no documentation for a request to fix the medication refrigerator inside the medication room for 11/2023. During an interview on 11/3/2023 at 4:14 p.m. with the Maintenance Supervisor (MS), the MS stated he was only notified yesterday, 11/2/2023, about the medication refrigerator in nursing station 1 medication room not working. The MS stated he had the medication refrigerator in the medication room replaced because it had ice buildup. The MS stated the medication refrigerator rooms are not part of his daily checks. The MS stated he will only check the medication refrigerator when the licensed nurses notify him either verbally or by writing on the maintenance log. A review of the facility's policy and procedure titled, Refrigerators and Freezers, reviewed 12/15/2022, indicated that the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. The procedure indicated the supervisor takes immediate action if temperatures are out of range, actions that are necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. A review of the facility's policy and procedure titled, Medication Storage and Labeling, reviewed 3/9/2023, indicated it is the facility's policy that drugs requiring refrigeration shall be stored in a refrigerator between 36 F and 46 F. The procedure indicated that drugs shall be stored in appropriate temperatures and drugs requiring refrigeration shall be stored in a refrigerator between 36 F and 46 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 45 of 45