Health inspection·November 27, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few side while walking in the hallway by himself using a cane. RN 1 stated resident fell in front of Room F while Certified Nursing Assistant 1 was coming out of Room E. During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1 ' s SBAR dated 11/16/2023 was reviewed. The SBAR indicated a resident pushed Resident 1. The DON stated they did not report the incident to the State Survey Agency (SSA), the Ombudsman and local law enforcement because the incident was witnessed by RN 1 that no one pushed the resident on 11/16/2023. During an interview on 11/27/2023 at 11:27 a.m., RN 1 stated Resident 1 had history of confusion and initially reported he was pushed by a resident and then later reported he fell by himself. RN 1 stated it was not allegation of abuse because he witnessed no one pushed Resident 1. During an interview on 11/27/2023 at 11:37 a.m., the Director of Staff Development (DSD) stated he reviewed the SBAR dated 11/16/2023 that indicated Resident 1 reported to RN 1 that he was pushed. The DSD stated the allegation of abuse should have investigated and reported to SSA, the Ombudsman and local law enforcement within two hours. The DSD stated RN 1 should have reported the incident as soon as the resident reported that someone pushed him. During an interview on 11/27/2023 at 11:44 a.m., with the Administrator, the (ADM) stated a resident reporting someone pushed him is an allegation of abuse. A review of facility ' s policy and procedure titled, Abuse Investigation and Reporting dated 12/24/2020 and reviewed on 11/15/2023, indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility Administrator or designee, or his/her designee, to the following persons or agencies: a. State licensing/certification agency responsible for surveying/ licensing the facility. b. the local Ombudsman. e. Law enforcement officials. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). On 11/16/2023 Resident 1 reported to Registered Nurse 1 (RN 1) that someone pushed him causing him to fall to the ground. The facility did not investigate and reported the allegation of abuse to the SSA. This deficient practice had the potential to result in harm to residents from uninvestigated allegations of abuse. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 1/6/2023 with diagnoses that included pneumonitis (inflammation of lung tissue) due to inhalation (the process by which air enter your lungs) of food and vomit (the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose), hypotension (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 2 of 10 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 11/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm (uncontrolled low blood pressure), muscle weakness and Alzheimer's Disease (brain condition that causes a worsening decline in memory, thinking, learning and organizing skills). A review of Resident 1's History and Physical dated 3/23/2023 indicated the resident had no capacity to understand and make decisions. Residents Affected - Few A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/3/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required moderate assistance from staff while walking between 10 to 50 feet. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident's condition), dated 11/16/2023 indicated Resident 1 reported to Registered Nurse 1 (RN 1) that a resident pushed him. A review of Resident 1's Interdisciplinary Team (IDT- professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) Note dated 11/17/2023 indicated Resident 1 initially stated that someone pushed him. During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated on 11/16/2023 between 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A when he saw Resident 1 falling on his right side while walking in the hallway by himself using a cane. RN 1 stated resident fell in front of Room F while Certified Nursing Assistant 1 was coming out of Room E. During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1's SBAR dated 11/16/2023 was reviewed. The SBAR indicated a resident pushed Resident 1. The DON stated they did not report the incident to the State Survey Agency (SSA), the Ombudsman and local law enforcement because the incident was witnessed by RN 1 that no one pushed the resident on 11/16/2023. During an interview on 11/27/2023 at 11:27 a.m., RN 1 stated Resident 1 had history of confusion and initially reported he was pushed by a resident and then later reported he fell by himself. RN 1 stated it was not allegation of abuse because he witnessed no one pushed Resident 1. During an interview on 11/27/2023 at 11:37 a.m., the Director of Staff Development (DSD) stated he reviewed the SBAR dated 11/16/2023 that indicated Resident 1 reported to RN 1 that he was pushed. The DSD stated the allegation of abuse should have investigated and reported to SSA, the Ombudsman and local law enforcement within two hours. The DSD stated RN 1 should have reported the incident as soon as the resident reported that someone pushed him. During an interview on 11/27/2023 at 11:44 a.m., with the Administrator, the (ADM) stated a resident reporting someone pushed him is an allegation of abuse. A review of facility's policy and procedure titled, Abuse Investigation and Reporting dated 12/24/2020 and reviewed on 11/15/2023, indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility Administrator or designee, or his/her designee, to the following persons or agencies: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 3 of 10 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 11/27/2023 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 0609 a. State licensing/certification agency responsible for surveying/ licensing the facility. Level of Harm - Minimal harm or potential for actual harm b. the local Ombudsman. e. Law enforcement officials. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 4 of 10 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 11/27/2023 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had three falls at the facility since admission and needed moderate assistance from staff (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet) when walking, was free of accidents and injury. The facility failed to provide Resident 1 supervision and assistance in accordance with the assessment and plan of care. As a result, on 11/16/2023, Resident 1 sustained an acute fracture (sudden break of a bone) of the femoral component (generally made of metal, and curves around the end of the femur [thigh bone]) of the right total hip arthroplasty (damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/6/2023 with diagnoses including essential (primary) hypertension (high blood pressure that does not have a known cause), muscle weakness, history of fall, personal history of (healed) fractures, bilateral (both) hip replacement, cancer of the throat and lungs, and Alzheimer ' s disease (brain condition that causes a worsening decline in memory, thinking, learning, and organizing skills). A review of Resident 1 ' s History and Physical exam, dated 3/23/202,3 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet). The MDS also indicated resident had one episode of fall with injury since admission and had a bed alarm (device that contains sensors that trigger an alarm or warning light when they detect a change in pressure; the sensor pads are generally placed either under the shoulder area, or under the hip area, underneath the sheets on the mattress).The MDS also indicated Resident 1 was receiving active (resident participated) range of motion (ROM, moving the joints) exercises and walking exercises by restorative nursing assistant (RNA, nursing assistant trained to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). The MDS indicate Resident 1 did not use assistive devices with walking (cane or walker). A review of Resident 1 ' s Care Plan developed for the resident ' s fall risk, dated 1/11/2023, included in the interventions assisting Resident 1 with activities of daily living (ADL- such as walking, dressing and personal hygiene), providing a safe environment, observing / anticipating / intervening for factors causing prior falls (e.g., bowel and bladder urgency, mobility problem (standing, transferring, walking); ROM exercises or assist with ambulation if ordered. A review of Resident 1 ' s Care plan for potential for complications, dated 1/11/2023, indicated an intervention to observe, anticipate (expect), intervene for factors causing prior falls (example (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 5 of 10 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 11/27/2023 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 given bowel/bladder urgency [sudden], mobility problem- standing, transferring, walking) and range of motion exercises or assists ambulation as ordered. Level of Harm - Actual harm Residents Affected - Few A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident ' s condition), dated 1/13/2023, indicated Resident 1 claimed he fell on 1/13/2023 at noon. The SBAR indicated resident was assessed with yellowish to bluish discoloration to right hand. A review of Resident 1 ' s SBAR, dated 3/17/2023, indicated that around 4:45 p.m., Resident 1 was found on the floor, by his bed, lying on his left side with a bump on the left forehead. A review of the Physician ' s Order for Resident 1, dated 3/22/2023, indicated to apply a bed alarm to remind Resident 1 to ask for assistance when getting out of bed. A review of Resident 1 ' s SBAR, dated 9/22/2023, indicated Resident 1 was found at 7 a.m. lying on the floor, near the foot of the bed. Resident 1 had redness and scratched skin to back. The SBAR documentation did not include if the bed alarm was in place and functioning. A review of Resident 1 ' s Care Plan for the actual fall sustained on 9/22/2023, included in the interventions monitoring effectiveness / response to the plan of care. A review of Resident 1 ' s Fall Risk Evaluation, dated 11/3/2023, indicated resident had one to two episodes of fall in the past three months. A review of Resident 1 ' s SBAR, dated 11/16/2023, indicated Certified Nursing Assistant 2 (CNA 2) reported to Registered Nurse 1 (RN 1) that resident was found lying on the floor, in the hallway, and was complaining of right hip pain. The SBAR indicated the attending physician was notified and ordered X-rays (type of radiation used to create a picture of the inside of the body) of both hips. A review of Resident 1 ' s SBAR, dated 11/17/2023, indicated resident had worsening right hip pain, the severity was six of ten (6/10, in a pain scale for zero to 10; zero indicating no pain and 10 the worst pain possible). The Nurse Practitioner (NP) ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1). A review of Resident 1 ' s Progress Note, dated 11/18/2023, indicated RN 3 from General Acute Care Hospital 1 (GACH 1) notified the Director of Nursing (DON) Resident 1 was diagnosed with had a right femur fracture (break in the thigh bone). During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated Resident 1 was ambulatory with unsteady gait (unstable pattern of walking) and had previous history of fall. RN 1 stated on 11/16/2023 he worked in the unit for residents with Coronavirus Disease - 2019 (COVID-19, - highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) which had 40 residents, including Resident 1. RN 1 stated he had documented CNA 2 informed him of finding Resident 1 on the floor, during the interview, RN 1 stated that around 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A about to give medications when he saw Resident 1 falling on his right side while walking in the hallway by himself using a straight cane. RN 1 stated resident fell in front of Room F while CNA 2 was coming out of Room E. RN 1 stated the fall could have been avoided if CNA 2 stayed with the resident while he was walking in the hallway. RN 1 stated CNA 2 should have stayed with the resident and asked another staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 6 of 10 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 11/27/2023 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 to look for the resident ' s eyeglasses instead of leaving him by himself. Level of Harm - Actual harm During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1 ' s MDS, dated [DATE], and SBARs, dated 1/13/2023, 3/17/2023, 9/22/2023 and 11/16/2023, were reviewed. The MDS, dated [DATE], indicated resident needed moderate assistance and the SBARs all indicated Resident 1 ' s fall. The DON stated moderate assistance means resident should walk with a staff beside him. The DON stated CNA 2 should have stayed with him while he was walking in the hallway. The DON stated they were not able to provide supervision that day to resident 1 causing his fall. Residents Affected - Few During a concurrent interview and record review on 11/27/2023 at 11:12 a.m., with Physical Therapist 1 (PT 1), Resident 1 ' s Physical Therapist Discharge Summary (DC Summary), dated 3/23/2023 to 4/20/2023, was reviewed. The DC Summary indicated on 4/20/23 resident was able to ambulate 150 feet with standby assists from staff using a single point cane (SPC). PT 1 stated standby assists meant staff should be next to the resident while walking. During an interview on 11/27/2023 at 11:44 a.m., the Administrator (ADM) stated fall was avoidable if CNA 2 stayed with Resident 1 while he was walking in the hallway. A review of Resident 1 ' s GACH 1 History and Physical Reports, dated 11/20/2023, indicated Resident 11 was admitted because of a right hip fracture after a fall and the orthopedic surgeon (doctor who specializes in surgery of bones, joints, and muscles) was consulted and no surgery was indicated. A review of Resident 1 ' s GACH 1 Final Report, dated 11/20/2023, indicated a Computed Tomography (CT scan - an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the right hip showed acute fracture of the femoral component of the right total hip arthroplasty with multiple fractures involving the greater trochanter (a four-sided bony prominence located at the upper part of the femur) and extending inferiorly (lower part). A review of facility ' s policy and procedure titled, Safety and Supervision of Residents, dated 7/2017 and reviewed on 3/9/2023, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accidents hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent avoidable accidents. Resident supervision is a core component of the systems approach to safety. They type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had three falls at the facility since admission and needed moderate assistance from staff (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet) when walking, was free of accidents and injury. The facility failed to provide Resident 1 supervision and assistance in accordance with the assessment and plan of care. As a result, on 11/16/2023, Resident 1 sustained an acute fracture (sudden break of a bone) of the femoral component (generally made of metal, and curves around the end of the femur [thigh bone]) of the right total hip arthroplasty (damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 7 of 10 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 11/27/2023 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 Findings: Level of Harm - Actual harm A review of Resident 1's admission Record indicated the facility admitted the resident on 1/6/2023 with diagnoses including essential (primary) hypertension (high blood pressure that does not have a known cause), muscle weakness, history of fall, personal history of (healed) fractures, bilateral (both) hip replacement, cancer of the throat and lungs, and Alzheimer's disease (brain condition that causes a worsening decline in memory, thinking, learning, and organizing skills). Residents Affected - Few A review of Resident 1's History and Physical exam, dated 3/23/202,3 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet). The MDS also indicated resident had one episode of fall with injury since admission and had a bed alarm (device that contains sensors that trigger an alarm or warning light when they detect a change in pressure; the sensor pads are generally placed either under the shoulder area, or under the hip area, underneath the sheets on the mattress).The MDS also indicated Resident 1 was receiving active (resident participated) range of motion (ROM, moving the joints) exercises and walking exercises by restorative nursing assistant (RNA, nursing assistant trained to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). The MDS indicate Resident 1 did not use assistive devices with walking (cane or walker). A review of Resident 1's Care Plan developed for the resident's fall risk, dated 1/11/2023, included in the interventions assisting Resident 1 with activities of daily living (ADL- such as walking, dressing and personal hygiene), providing a safe environment, observing / anticipating / intervening for factors causing prior falls (e.g., bowel and bladder urgency, mobility problem (standing, transferring, walking); ROM exercises or assist with ambulation if ordered. A review of Resident 1's Care plan for potential for complications, dated 1/11/2023, indicated an intervention to observe, anticipate (expect), intervene for factors causing prior falls (example given bowel/bladder urgency [sudden], mobility problem- standing, transferring, walking) and range of motion exercises or assists ambulation as ordered. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident's condition), dated 1/13/2023, indicated Resident 1 claimed he fell on 1/13/2023 at noon. The SBAR indicated resident was assessed with yellowish to bluish discoloration to right hand. A review of Resident 1's SBAR, dated 3/17/2023, indicated that around 4:45 p.m., Resident 1 was found on the floor, by his bed, lying on his left side with a bump on the left forehead. A review of the Physician's Order for Resident 1, dated 3/22/2023, indicated to apply a bed alarm to remind Resident 1 to ask for assistance when getting out of bed. A review of Resident 1's SBAR, dated 9/22/2023, indicated Resident 1 was found at 7 a.m. lying on the floor, near the foot of the bed. Resident 1 had redness and scratched skin to back. The SBAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 8 of 10 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 11/27/2023 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 documentation did not include if the bed alarm was in place and functioning. Level of Harm - Actual harm A review of Resident 1's Care Plan for the actual fall sustained on 9/22/2023, included in the interventions monitoring effectiveness / response to the plan of care. Residents Affected - Few A review of Resident 1's Fall Risk Evaluation, dated 11/3/2023, indicated resident had one to two episodes of fall in the past three months. A review of Resident 1's SBAR, dated 11/16/2023, indicated Certified Nursing Assistant 2 (CNA 2) reported to Registered Nurse 1 (RN 1) that resident was found lying on the floor, in the hallway, and was complaining of right hip pain. The SBAR indicated the attending physician was notified and ordered X-rays (type of radiation used to create a picture of the inside of the body) of both hips. A review of Resident 1's SBAR, dated 11/17/2023, indicated resident had worsening right hip pain, the severity was six of ten (6/10, in a pain scale for zero to 10; zero indicating no pain and 10 the worst pain possible). The Nurse Practitioner (NP) ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1). A review of Resident 1's Progress Note, dated 11/18/2023, indicated RN 3 from General Acute Care Hospital 1 (GACH 1) notified the Director of Nursing (DON) Resident 1 was diagnosed with had a right femur fracture (break in the thigh bone). During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated Resident 1 was ambulatory with unsteady gait (unstable pattern of walking) and had previous history of fall. RN 1 stated on 11/16/2023 he worked in the unit for residents with Coronavirus Disease - 2019 (COVID-19, - highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) which had 40 residents, including Resident 1. RN 1 stated he had documented CNA 2 informed him of finding Resident 1 on the floor, during the interview, RN 1 stated that around 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A about to give medications when he saw Resident 1 falling on his right side while walking in the hallway by himself using a straight cane. RN 1 stated resident fell in front of Room F while CNA 2 was coming out of Room E. RN 1 stated the fall could have been avoided if CNA 2 stayed with the resident while he was walking in the hallway. RN 1 stated CNA 2 should have stayed with the resident and asked another staff to look for the resident's eyeglasses instead of leaving him by himself. During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1's MDS, dated [DATE], and SBARs, dated 1/13/2023, 3/17/2023, 9/22/2023 and 11/16/2023, were reviewed. The MDS, dated [DATE], indicated resident needed moderate assistance and the SBARs all indicated Resident 1's fall. The DON stated moderate assistance means resident should walk with a staff beside him. The DON stated CNA 2 should have stayed with him while he was walking in the hallway. The DON stated they were not able to provide supervision that day to resident 1 causing his fall. During a concurrent interview and record review on 11/27/2023 at 11:12 a.m., with Physical Therapist 1 (PT 1), Resident 1's Physical Therapist Discharge Summary (DC Summary), dated 3/23/2023 to 4/20/2023, was reviewed. The DC Summary indicated on 4/20/23 resident was able to ambulate 150 feet with standby assists from staff using a single point cane (SPC). PT 1 stated standby assists meant staff should be next to the resident while walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 9 of 10 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 11/27/2023 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 During an interview on 11/27/2023 at 11:44 a.m., the Administrator (ADM) stated fall was avoidable if CNA 2 stayed with Resident 1 while he was walking in the hallway. Level of Harm - Actual harm Residents Affected - Few A review of Resident 1's GACH 1 History and Physical Reports, dated 11/20/2023, indicated Resident 11 was admitted because of a right hip fracture after a fall and the orthopedic surgeon (doctor who specializes in surgery of bones, joints, and muscles) was consulted and no surgery was indicated. A review of Resident 1's GACH 1 Final Report, dated 11/20/2023, indicated a Computed Tomography (CT scan - an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the right hip showed acute fracture of the femoral component of the right total hip arthroplasty with multiple fractures involving the greater trochanter (a four-sided bony prominence located at the upper part of the femur) and extending inferiorly (lower part). A review of facility's policy and procedure titled, Safety and Supervision of Residents, dated 7/2017 and reviewed on 3/9/2023, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accidents hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent avoidable accidents. Resident supervision is a core component of the systems approach to safety. They type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 10 of 10