Health inspection·November 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with CNA 6, on 11/5/2024, at 10:18 a.m., inside Resident 3's room, Resident 3 was lying in bed with the head of the bed elevated to seat Resident 3 upright. CNA 6 assisted Resident 3 with feeding an orange-colored gelatin while standing over the resident. CNA 6 stated she should be sitting at eye level with the resident while assisting the resident with eating to respect the dignity of the resident. Residents Affected - Some During an interview with Registered Nurse (RN) 5, on 11/8/2024, at 9:14 a.m., RN 5 stated when providing feeding assistance to residents, the facility staff should be sitting down and at eye level with the resident for the dignity of the resident. RN 5 further stated if not done, the residents can feel like they are being rushed and potentially feel disrespected. During an interview with the Director of Nursing (DON), on 11/8/2024, at 1:52 p.m., the DON stated staff should be sitting down at eye level with the resident while assisting residents with feeding. The DON further stated standing over the residents while feeding them can negatively affect the resident's self-esteem and self-worth and potentially make the residents feel disrespected. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, last reviewed 7/19/2024, the P&P indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity such as not standing over residents while assisting them with meals. 2. During a review of Resident 52's admission Record, the admission Record indicated the facility originally admitted Resident 52 on 8/24/2018 and readmitted the resident on 9/8/2020 with diagnoses including dementia (a progressive state of decline in mental abilities) and dependence on wheelchair. During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 had short-term and long-term memory problems and severe daily decision-making impairment, and required maximal assistance or was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers. During a review of Resident 52's H&P, dated 7/2/2024, the H&P indicated Resident 52 has fluctuating capacity to understand and make informed decisions. During a review of Resident 52's Order Summary Report, dated 10/12/2023, the Order Summary Report indicated Resident 52 was ordered snack three times a day for supplements. During a concurrent observation and interview, on 11/5/2024, at 10:37 a.m., inside the small activity room, AA 1 was standing over Resident 52 while holding a cup next to the resident's face. Resident 52 drank from the cup. AA 1 stated when providing hydration to residents, AA 1 is usually standing over the residents and has not been informed that they should not be standing over the resident while providing hydration. During an interview with RN 5, on 11/8/2024, at 9:14 a.m., RN 5 stated when providing feeding assistance to residents, the facility staff should be sitting down and at eye level with the resident for the dignity of the resident. RN 5 further stated if not done, the residents can feel like they are being rushed and potentially feel disrespected. During an interview with the DON, on 11/8/2024, at 1:52 p.m., the DON stated staff should be sitting down at eye level with the resident while assisting residents with feeding. The DON further stated standing over the residents while feeding them can negatively affect the resident's self-esteem and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 2 of 70 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 11/08/2024 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 0550 self-worth and potentially make the residents feel disrespected. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Assistance with Meals, last reviewed 7/19/2024, the P&P indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity such as not standing over residents while assisting them with meals. Residents Affected - Some 3. During a review of Resident 94's admission Record, dated 10/29/2024, the admission Record indicated the facility admitted Resident 94 on 10/9/2024 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), benign prostatic hyperplasia (BPH, enlargement of the prostate gland that may result in urinary retention) with lower urinary tract symptoms, and dementia. During a review of Resident 94's H&P, dated 10/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 had the ability to understand others and the ability to be understood. The MDS further indicated the resident required substantial/maximal assistance with toileting, bathing, dressing, and personal hygiene. The MDS indicated the resident had an indwelling catheter. During a review of Resident 94's Care Plan regarding bowel incontinence, initiated 10/20/2024, the Care Plan indicated the resident uses disposable briefs that are changed as needed. During an observation on 11/8/2024 at 9:10 a.m., inside of Resident 94's room, Resident 94 lay in bed while assisted by TN 1 and CNA 2 with indwelling catheter care. Observed Resident 94 wore a disposable brief. While providing catheter care, TN 1 stated to Resident 94 that the resident's diaper would be changed. CNA 2 also stated to Resident 94 that the resident's diaper would be changed. While assisting Resident 94 to change the disposable brief, TN 1 repeated the word diaper three more times and CNA 2 also repeated the word diaper three more times. During an interview on 11/8/2024, at 9:35 a.m., with CNA 2, CNA 2 stated he changed Resident 94's diaper. CNA 2 stated he knew only the word diaper, and he did not know a different word to refer to the resident's diaper. During an interview on 11/8/2024, at 9:40 a.m., with TN 1, TN 1 stated normally the staff should use the word disposable instead of diaper while providing care for residents. TN 1 stated he and CNA 2 used the word diaper with Resident 94. TN 1 stated they should have told Resident 94 they were providing dignity care with a disposable, but they did not. TN 1 stated using the word diaper may cause a dignity issue for Resident 94 and the resident may feel bad. During an interview on 11/8/2024 at 9:55 a.m. with the DON, the DON stated the facility uses the term disposable briefs with residents. The DON stated the staff should not refer to a disposable brief as a diaper because it is a dignity issue. The DON stated the work diaper is used for babies and not adults. The DON stated when staff uses the word diaper with residents it may cause them to feel bad resulting in a self-esteem issue. During a review of the facility P&P titled, Resident Rights, last reviewed 7/19/2024, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state law guarantees certain basic rights to all residents of the facility. These rights include the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 3 of 70 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 11/08/2024 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 0550 right to a dignified existence. Level of Harm - Minimal harm or potential for actual harm During a review of the facility P&P titled, Quality of Life, Dignity, last reviewed 7/19/2024, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with Dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall speak respectfully to residents at all times. Demeaning practices that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by addressing the use of incontinent material such as incontinent pad and cloth protector. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 4 of 70 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 11/08/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) out of 1 sampled resident (Resident 60) investigated during a review of physical restraints care area by failing to obtain a physician's order, informed consent from the resident and/or resident representative, and complete a restraint assessment prior to use of the pommel cushion (a cushion for wheelchair designed to maintain proper hip and leg alignment, reduce the risk of inward movement of the legs, and prevent the patient from sliding forward in the seat). Residents Affected - Some These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by in a position that they cannot move from), and death of residents. Findings: During a review of Resident 60's admission Record, the admission Record indicated the facility admitted the resident on 2/16/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and generalized muscle weakness. During a review of Resident 60's History and Physical (H&P),dated 7/2/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions. During a review of Resident 60's Fall Risk Evaluations, dated 7/11/2024, 7/31/2024, and 10/23/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, chair-bound, and requires use of assistive device when ambulating. During a review of Resident 60's Minimum Data Set (MDS-a resident assessment tool) dated 10/21/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required staff assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 60's Order Summary Report, the Order Summary Report did not indicate an order for the use of pommel cushion. During a concurrent observation and interview on 11/5/2024 at 10:37 a.m. inside Dining room [ROOM NUMBER] (DR 1) with Activity Assistant 1 (AA 1), observed Resident 60 sitting on a wheelchair with a cushion with raised center section. Observed Resident 60 making an up and down movement while sitting on the wheelchair. AA 1 verified Resident 60 has been on that type of cushion to prevent the resident from sliding out of the wheelchair due to incidents of falls in the past. AA 1 was unable to tell what the device is called. During an interview on 11/7/2024 at 9:30 a.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 5 of 70 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 11/08/2024 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 verified the staff have been using the pommel cushion on Resident 60 for a while now but was unable to recall how long the resident had been on the pommel cushion. RNA 1 stated the pommel cushion was used to prevent Resident 60 from sliding out of the wheelchair due to previous history of falls. During an interview on 11/7/2024 at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 verified that they have been using the pommel cushion for Resident 60 to prevent the resident from sliding out of the wheelchair and fall. CNA 3 was unable to recall when the staff started using the pommel cushion on Resident 60, but it had been a while. CNA 3 verified he placed the pommel cushion on 11/5/2024 but was instructed by the supervisor to remove the cushion. During a concurrent observation and interview on 11/7/2024 at 9:40 a.m., reviewed Resident 60's medical records including physician's orders, care plan, informed consents, and restraint assessments with Registered Nurse 2 (RN 2). RN 2 stated if a device is being used on a resident, there should be a physician's order, informed consent from the resident or resident representative, and restraint assessment prior to use of the pommel cushion. RN 2 verified the pommel cushion restricts Resident 60's movement by preventing the resident from sliding out of the wheelchair. RN 2 verified there was no physician's order, informed consent, and restraint assessment for Resident 60's use of pommel cushion. RN 2 stated a physician's order should have been obtained, informed consent should have been obtained from the resident or resident representative, and restraint assessment completed prior to use of the pommel cushion to determine appropriateness of the device, and for the resident and/or resident representative to be aware of the risks and benefits of the device use. RN 2 stated if there was no physician's order, the staff would not be aware of the resident's plan of care. During a concurrent interview and record review on 11/8/2024 at 3 p.m., reviewed the facility 's policy and procedure (P&P) titled, Use of Restraints, with the Director of Nursing (DON). The DON stated she asked CNA 3 to remove the pommel cushion on Resident 60 as the resident did not have a physician's order for the device cushion. The DON stated the pommel cushion can restrict Resident 60's movement by preventing the resident from sliding off the wheelchair. The DON stated prior to using a device on a resident, a physician's order, informed consent from the resident and/or resident representative should have been obtained, and a restraint or device use assessment should have been completed prior to use of the pommel cushion. The DON verified the facility did not follow the P&P as evidenced by using the pommel cushion without a physician's order, no informed consent from the resident and/or resident representative, and the restraint or device use assessment was not completed prior to use of the pommel cushion. The DON stated the purpose of a physician's order and informed consent is to ensure staff, resident and/or resident representative were aware of the resident's plan of care, and the risks and benefits of the restraint use. The DON stated purpose of restraint or device use assessment is to determine appropriateness of the use of pommel cushion. During a review of the facility's P&P titled, Use of Restraints, last reviewed 7/19/2024, the P&P indicated the following: Restraints shall only be used for the safety and well-being of the resident/s and after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 6 of 70 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 11/08/2024 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 staff convenience, or for the prevention of falls. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including placing a resident in a chair that prevents the resident from rising. There shall be a pre-restraining assessment and review to determine the need for restraints prior to placing to placing a resident in restraints. Restraint shall only be used upon the written physician's order and after obtaining consent form the resident and/or resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 7 of 70 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 11/08/2024 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** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (3) sampled residents (Residents 60, 17, and 57) investigated under the accidents care area and one (1) out of two (2) sampled residents (Resident 3) investigated under the respiratory care area: 1. By failing to develop a care plan addressing the use of pommel cushion (a cushion for wheelchair designed to maintain proper hip and leg alignment, reduce the risk of inward movement of the legs, and prevent the patient from sliding forward in the seat) for Resident 60. 2. By failing to develop a care plan addressing the use of floor mat (a cushioned floor pad designed to help prevent injury should a person fall) for Resident 17. 3. By failing to develop the Resident 57's care plan addressing the placement of a medical equipment on the resident's floor mat. 4. By failing to address Resident 3's care plan addressing oxygen use. These failures had the potential to cause a delay in the delivery of necessary care and services the residents need. Findings: a. During a review of Resident 60's admission Record, the admission Record indicated the facility admitted the resident on 2/16/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and generalized muscle weakness. During a review of Resident 60's History and Physical (H&P), dated 7/2/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions. During a review of Resident 60's Fall Risk Evaluations, dated 7/11/2024, 7/31/2024, and 10/23/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, chairbound, and requires use of assistive device when ambulating. During a review of Resident 60's Care Plan addressing the resident's risk for fall related to gait/balance problems, decreased safety judgement initiated on 2/21/2023 and last revised 8/14/2024, the Care Plan did not indicate the use of pommel cushion as one of the interventions. During a review of Resident 60's Minimum Data Set (MDS-a resident assessment tool), dated 10/21/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required staff assistance on mobility and activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 11/5/2024 at 10:37 a.m. inside Dining room [ROOM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 8 of 70 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 11/08/2024 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 NUMBER] (DR 1) with Activity Assistant 1 (AA 1), observed resident sitting on a wheelchair with a cushion with raised center section. Observed Resident 60 making an up and down movement while sitting on the wheelchair. AA 1 verified Resident 60 has been on that type of cushion to prevent the resident from sliding out of the wheelchair due to incidents of falls in the past. During a concurrent interview and record review on 11/7/2024 at 2:30 p.m., reviewed Resident 60's medical records including physician orders and care plans with Registered Nurse 2 (RN 2). RN 2 verified Resident 60 did not have a care plan for the use of pommel cushion. RN 2 stated if a device is being used on a resident, a care plan should be developed as it serves as a guide for staff how to provide care to the resident. RN 2 stated a care plan should have been developed for the use of the pommel cushion. During an interview on 11/8/2024 at 2:49 p.m., with the Director of Nursing (DON), the DON stated she was made aware there was no care plan developed for the continued use of pommel cushion. The DON stated the care plan should have been developed for the continued use of the pommel cushion. The DON stated the purpose of the care plan is to customize the care for the resident. The DON stated when a care plan is not developed, the staff will not have a guide on how to provide care to the resident which can lead to a delay in care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. b. During a review of Resident 17's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2014 and readmitted in the facility on 5/10/2021 with diagnoses including dementia, abnormalities of gait and mobility, and muscle wasting and atrophy (the wasting away or shrinkage of an organ or tissue due to lack of use or aging). During a review of Resident 17's H&P dated 7/19/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions. During a review of Resident 17's Fall Risk Evaluations, dated 4/11/2024, 7/9/2024, and 10/7/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, and chairbound. During a review of Resident 17's MDS dated [DATE], the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS indicated the resident required maximal to total assistance from staff on mobility and activities of daily living. During a concurrent observation and interview on 11/5/2024 at 10 a.m. inside Resident 17's room with Certified Nursing Assistant 4 (CNA 4), observed Resident 17's wheelchair and overbed table placed on top of the left side floor mat. During an observation on 11/7/2024 at 3:50 p.m., inside Resident 17's room with Registered Nurse 2 (RN 2). RN 2 verified Resident 17 had floor mat on the left of the bed with the wheelchair left on top. During a concurrent interview and record review on 11/7/2024 at 3:55 p.m., reviewed Resident 17's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 9 of 70 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 11/08/2024 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 Care Plan on risk for fall due to needs assistance with transfers and ambulation related to gait/balance problems initiated on 4/15/2015 and last revised on 2/23/2022. The Care Plan indicated the use of floor mats at the sides of the bed as an intervention was in resolved status on 3/13/2017. RN 2 stated Resident 17 did not have a current intervention in the CP addressing the use of left side floor mat. RN 2 stated the purpose of care plan is so the staff would know what the interventions in place are to minimize resident's risk for falls and prevent delay in care of the resident. During a concurrent interview and record review on 11/8/2024 at 2:55 p.m., reviewed Resident 17's Care Plan on risk for fall with the DON. The DON verified the Care Plan did indicate floor mat as one of the interventions to prevent resident falls. The DON stated the care plan should have been developed for the continued use of the floor mat. The DON stated the purpose of the care plan is to customize the care for the resident. The DON stated when a care plan is not developed, the staff will not have a guide on how to provide care to the resident which can lead to a delay in care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. d. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/10/2010 and readmitted the resident on 10/1/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), abnormal weight loss, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and other lack of coordination. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had short-term and long-term memory problems and severe daily decision-making impairment, and was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers. The MDS further indicated Resident 3 received oxygen therapy. During a review of Resident 3's H&P dated 10/17/2024, the H&P indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Order Summary Report, dated 10/16/2024, the Order Summary Report indicated to administer oxygen at two to three liters (a unit of measure for volume) per minute via nasal cannula or mask to maintain an oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) greater than 92 percent (%) every shift for episodes of low oxygen saturation. During a review Resident 3's Treatment Administration Record (TAR), dated 11/5/2024, the TAR indicated Resident 3 was administered oxygen at two to three liters per minute via nasal cannula or mask to maintain an oxygen saturation greater than 92%. During an observation on 11/5/2024, at 10:18 a.m., inside Resident 3's room, Resident 3 was lying in bed with a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) connected to Resident 3's nose. The oxygen concentrator (a medical device that provides extra oxygen) connected to the nasal cannula indicated Resident 3 was receiving oxygen at three liters per minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 10 of 70 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 11/08/2024 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 During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 11/8/2024, at 8:52 a.m., Resident 3's Care Plan titled, [Resident 3] is at risk for respiratory distress related to asthma [a chronic lung disease that causes the airways in the lungs to narrow and swell, making it difficult to breathe]/COPD ., initiated 1/3/2015, was reviewed and the MDSC confirmed and stated Resident 3 did not have interventions for oxygen administration. The MDSC stated it is important to include an oxygen administration intervention so that the facility staff know what to do when the resident is experiencing shortness of breath. The MDSC stated the purpose of a care plan is to help guide the facility staff on how to provide care. During a concurrent interview and record review with Registered Nurse (RN) 5, on 11/8/2024, at 9:04 a.m., Resident 3's care plans, current as of 11/8/2024, were reviewed and RN 5 confirmed Resident 3 did not have current care plans with interventions including administration of oxygen. RN 5 stated it is important for the resident's current conditions to have supporting interventions for nursing staff to be guided on what to do for specific conditions. RN 5 further stated if the interventions are not in place in the care plans there would be a potential delay in care. During an interview with the DON on 11/8/2024, at 1:52 p.m., the DON stated Resident 3 has a history of COPD and his care plans for COPD should include interventions to administer oxygen. The DON stated the purpose of a care plan is to customize care for the resident and to guide the staff on how to provide care to the resident. The DON further stated without an intervention for Resident 3's COPD, there is a potential for decreased oxygen levels and respiratory failure and case a potential delay in care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered), last reviewed 7/19/2024, the P&P indicated the comprehensive, person-centered care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, aid in preventing or reducing decline in the resident's functional status and/or functional levels, and reflect currently recognized standards of practice for problem areas and conditions. c. During a review of Resident 57's admission Record, the admission Record indicated the facility originally admitted the resident on 12/6/2022 and readmitted the resident on 10/25/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side and right dominant side, dementia, and history of falling. During a review of Resident 57's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required staff assistance on mobility and activities of daily living. During a review of Resident 57's H&P dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 57's Fall Risk Evaluation, dated 10/25/2024, the Fall Risk Evaluation indicated the resident had one to two falls in the past three months, was chairbound, and required assistance with elimination. During a review of Resident 57's Care Plan addressing the resident at risk for fall, dated 10/29/2024, the Care Plan interventions included applying floor mat on both sides of the bed as ordered to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 11 of 70 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 11/08/2024 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 decrease injury in the event of a fall. Level of Harm - Minimal harm or potential for actual harm During an observation on 11/5/2024 at 8:39 a.m., inside Resident 57's room, observed bilateral floor mats by resident's bed and a wheelchair sitting on top of Resident 57's left side floor mat. Residents Affected - Some During a concurrent observation and interview on 11/5/2024 at 10:28 a.m., inside Resident 57's room, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the wheelchair placed on top of Resident 57's left side floor mat belonged to Resident 38. CNA 1 stated she and another CNA have tried before to clear Resident 57's floor mat of Resident 38's wheelchair, but Resident 38 gets angry if his wheelchair was moved so CNA 1 kept it there all the time. CNA 1 stated Resident 38's wheelchair should be off the floor mat because it is used to prevent injury if Resident 57 falls out of bed. When asked if the floor mat would be effective in breaking Resident 57's fall if the wheelchair was kept on top of it, CNA 1 stated she does not know. During a concurrent observation and interview on 11/6/2024 at 1:04 p.m., inside Resident 57's room, with the DON, the DON stated Resident 38's wheelchair was on top of Resident 57's left side floor mat. During an interview on 11/6/2024 at 1:12 p.m., with the DON, the DON stated the floor mats are used to minimize injury for fall. The DON stated Resident 38's wheelchair should be removed because it would defeat the function of the floor mat for Resident 57's safety placing the resident at risk for injury. The DON stated it should be care planned if the roommate prefers to have their wheelchair on the side. The DON stated the nursing staff can try to ask Resident 38 if he can use the other side of his bed to place his wheelchair and clear Resident 57's left side. During a follow-up interview on 11/8/2024 at 2:10 p.m., the DON stated when the care plan is not developed to reflect the current response to the intervention, it can potentially harm the resident because Resident 57 might fall on the wheelchair instead of the floor mat. The DON stated the purpose of a care plan is to customize the care for the resident. The DON stated the care plans guide the staff on how to provide care to the resident and if there is no right intervention, it can cause a delay in care. During a review of the facility P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 12 of 70 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 11/08/2024 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** b.1. During a review of Resident 37's admission Record (a document containing demographic and diagnostic information) dated 11/7/2024, the admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM 2. Residents Affected - Some During a review of Resident 37's Order Summary Report, dated 11/7/2024, the Order Summary Report indicated Resident 37 was prescribed Novolog (fast-acting insulin) to inject per sliding scale subcutaneous ([SQ] - under the skin) before meals and at bedtime, starting 5/16/2024. During a review of Resident 37's Medication Administration Record ([MAR] - a record of mediations administered to residents), for November 2024, the MAR indicated Resident 37 was prescribed Novolog per sliding scale SQ before meals and at bedtime, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. During the same review, the MAR indicated Novolog SQ was administered by the following licensed nurses, on the following days, times, and sites: 11/6/2024 four (4) units ([un] - a measure of dosage for insulin) at 11:30 a.m. on Left Upper Quadrant ([LUQ] - upper left side of abdomen) by Licensed Vocational Nurse (LVN) 3 11/6/2024 six (6) un at 4:30 p.m. on LUQ by LVN 4 b.2. During a review of Resident 56's admission Record dated 11/6/2024, the admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM 2. During a review of Resident 56's Order Summary Report, dated 11/6/2024, the Order Summary Report indicated Resident 56 was prescribed Fiasp (rapid-acting insulin) to inject per sliding scale SQ before meals and at bedtime related to DM 2, starting 3/22/2024. During a review of Resident 56's MAR for November 2024, the MAR's indicated Resident 56 was prescribed Fiasp to inject per sliding scale SQ before meals and at bedtime related to DM 2, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. During the same review, the MAR indicated Fiasp SQ was administered by the following licensed nurses, on the following days, times, and sites: 11/4/2024 two (2) un at 9 p.m. on left arm by Registered Nurse (RN) 4 11/5/2024 two (2) un at 11:30 a.m. on left arm by RN 3 b.3. During a review of Resident 60's admission Record dated 11/6/2024, the admission Record indicated the resident was originally admitted to the facility on [DATE] with a diagnosis including DM 2. During a review of Resident 60's Order Summary Report, dated 11/6/2024, the Order Summary Report indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM2, starting 8/9/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 13 of 70 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 11/08/2024 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 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 60's MAR for November 2024, the MAR indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM 2, at 6:30 a.m. During the same review, the MAR indicated Lantus SQ was administered by the following licensed nurses, on the following days, times, and sites: Residents Affected - Some 11/2/2024 five (5) un at 6:30 a.m. on Right Lower Quadrant ([RLQ] - lower right side of abdomen) by LVN 5 11/3/2024 five (5) un at 6:30 a.m. on RLQ by LVN 5 During a concurrent interview and record review on 11/7/2024 at 12:57 p.m., with the DON, the DON reviewed Resident 37's, 56's and 60's MAsR for November 2024. The DON stated that for Residents 37, 56 and 60, the MARs indicated there were instances where the insulin administration sites were not rotated by several licensed nurses, as expected by facility policy, standard of practice, and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 37, 56 and 60 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites. During a review of the facility's policy & procedures (P&P,) titled Adverse Consequences and Medication Errors, last reviewed 7/19/2024, the P&P indicated: 2. An 'adverse consequence' is defined as an unpleasant symptoms or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a. adverse drug/medication reaction 3. An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug . 4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. During a review of facility's P&P titled, Insulin Administration, last reviewed 7/19/2024, the P&P indicated: To provide guidelines for the safe administration of insulin to residents with diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 14 of 70 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 11/08/2024 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 16.b. injection sites should be rotated, preferably within the same general area. Level of Harm - Minimal harm or potential for actual harm During a review of facility provided manufacturer's guide Instructions for Use for Fiasp, dated September 2017, the manufacturer's guide indicated to Change (rotate) your injection sites for each injection. Do not use the same injection site for each injection. Residents Affected - Some During a review of facility-provided manufacturer's guide Instructions for Use for Novolog, dated February 2023, the manufacturer's guide indicated to If you inject Novolog, change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) at the injection sites. Do not use the same injection site for each injection. Do not inject where the skin has pits, is thickened, or has lumps. Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin. During a review of manufacturer's guide for Injecting Lantus with a vial and syringe, dated 2022, the manufacturer's guide indicated to Change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged. During a review of facility-provided manufacturer's guideline on insulin glargine, last revised 6/2022, the manufacturer's guide indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia (low blood sugar), allergic reactions, injection site reactions, lipodystrophy, pruritus (itchiness), rash, edema (swelling), and weight gain. During a review of facility-provided manufacturer's guideline on insulin aspart, last revised 2/2023, the manufacturer's guide indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, and weight gain. Based on interview and record review, the facility failed to provide care in accordance with professional standards for four (4) of five (5) sampled residents (Resident 14, 37, 56 and 60) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. The deficient practice increased the risk that Residents 14, 37, 56 and 60 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2024 with diagnoses including type two diabetes mellitus (DM 2 - a long (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 15 of 70 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 11/08/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some term condition that causes the level of sugar in the blood to become too high), chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly which results in a buildup of excess fluid and waste in the body), and obesity (a condition that occurs when a person has abnormal or excessive fat accumulation that presents a risk to health). During a review of Resident 14's History and Physical (H&P) dated 7/10/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool) dated 9/24/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with eating and assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 14 had a diagnosis of DM 2 and received insulin. During a review of Resident 14's Order Summary Report, the Order Summary Report indicated the following physician's order: - 7/10/2024: insulin aspart (a fast-acting insulin used to treat high blood sugar that starts to work about 15 minutes after injection) injection solution 100 unit per milliliter (unit/ml - a unit of measurement) inject five (5) units SQ before meals and at bedtime for DM 2 hold if blood sugar (BS) less than (< - a unit of measurement) 100 or nothing by mouth (NPO). - 8/16/2024: insulin aspart injection solution 100 unit/ml inject SQ before meals and at bedtime for fingerstick blood sugar (FSBS). If BS <70 give Glucogel (a product used to treat low blood sugars absorbed through the lining of the mouth and helps increase the blood glucose within 15 minutes) 1 tube, 8 ounces (oz - a unit of measurement) orange juice or light snack if resident alert and able to take by mouth, if with altered level of consciousness give Glucagon (a hormone that increases blood sugar levels by stimulating the liver to release glucose into the bloodstream) 1 ampule (a small, sealed glass container that holds a liquid, usually a medication, that is intended to be injected) intramuscular (IM - injection within or into a muscle) recheck BS and call physician (MD). Inject as per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level): if 70 - 150 = zero (0) unit; <70 = Initiate hypoglycemia (low blood sugar) protocol and call MD; 151 - 200 = two (2) units; 201 - 250 = four (4) units; 251 - 300 = six (6) units; 301 350 = eight (8) units; 351 - 400 = ten (10) units; more than (>) 400 may give 12 units and call MD, SQ before meals and at bedtime for FSBS. - 8/16/2024: insulin glargine (a long-acting insulin used to control the amount of sugar in the blood of patients with diabetes) SQ solution 100 unit/ml inject 32 units SQ at bedtime for DM 2. During a review of Resident 14's Medication Administration Record (MAR) for 8/2024, 9/2024, and 10/2024, the MAR indicated insulin aspart and insulin glargine injection solution were administered as follows: - Insulin aspart injection solution 100 units/ml: 8/7/2024 4:30 p.m. SQ Abdomen - left lower quadrant (LLQ) 807/2024 9 p.m. SQ Abdomen - LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 16 of 70 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 11/08/2024 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 8/9/2024 9 p.m. SQ Abdomen - right upper quadrant (RUQ) Level of Harm - Minimal harm or potential for actual harm 8/10/2024 6:30 a.m. SQ Abdomen - RUQ 8/10/2024 4:30 p.m. SQ Abdomen - LLQ Residents Affected - Some 8/10/2024 9 p.m. SQ Abdomen - LLQ 8/12/2024 11:30 a.m. SQ Arm - left 8/12/2024 4:30 p.m. SQ Arm - left 8/13/2024 11:30 a.m. SQ Arm - left 8/13/2024 4:30 p.m. SQ Arm - left 8/15/2024 11:30 a.m. SQ Abdomen - left upper quadrant (LUQ) 8/15/2024 4:30 p.m. SQ Abdomen - LUQ 8/23/2024 11:30 a.m. SQ Abdomen - RUQ 8/23/2024 4:30 p.m. SQ Abdomen - RUQ 9/13/24 6:30 a.m. SQ Abdomen - right lower quadrant (RLQ) 9/13/24 11:30 a.m. SQ Abdomen - RLQ 9/21/24 9 p.m. SQ Abdomen - LUQ 9/22/24 6:30 a.m. SQ Abdomen - LUQ 9/23/24 9 p.m. SQ Abdomen - LUQ 9/24/24 6:30 a.m. SQ Abdomen - LUQ 9/27/24 9 p.m. SQ Abdomen - RUQ 9/28/24 6:30 a.m. SQ Abdomen - RUQ 9/21/24 9 p.m. SQ Abdomen - LUQ 9/22/24 6:30 a.m. SQ Abdomen - LUQ 10/19/24 9 p.m. SQ Abdomen - LLQ 10/20/24 6:30 a.m. SQ Abdomen - LLQ 10/25/24 9 p.m. SQ Abdomen - RLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 17 of 70 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 11/08/2024 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 10/26/24 6:30 a.m. SQ Abdomen - RLQ Level of Harm - Minimal harm or potential for actual harm 10/26/24 9 p.m. SQ Abdomen - RUQ 10/27/24 6:30 a.m. SQ Abdomen - RUQ Residents Affected - Some 10/25/24 9 p.m. SQ Abdomen - RLQ 10/26/24 6:30 a.m. SQ Abdomen - RLQ - Insulin glargine injection solution 100 units/ml: 8/12/24 9 p.m. SQ Abdomen - RUQ 8/13/24 9 p.m. SQ Abdomen - RUQ 8/15/24 9 p.m. SQ Abdomen - LUQ 8/16/24 9 p.m. SQ Abdomen - LUQ 10/06/24 9: p.m. SQ Abdomen - RUQ 10/07/24 9 p.m. SQ Abdomen - RUQ During a concurrent interview and record review on 11/7/2024 at 2:45 p.m., reviewed Resident 14's physician's orders, MAR, and location of administration sites for insulin aspart and insulin glargine injection solution for 8/2024, 9/2024, and 10/2024 with Registered Nurse 2 (RN 2). RN 2 stated insulin administration sites should be rotated. RN 2 verified the insulin administration sites were not rotated for Resident 14. RN 2 stated the insulin administration sites should have been rotated. RN 2 stated not rotating the insulin injection site can damage the tissues such as lumps and bruising. During a concurrent interview and record review on 11/8/2024 at 3:00 p.m., reviewed Resident 14's location of insulin administration sites for insulin aspart and insulin glargine for 8/2024, 9/2024, and 10/2024, policy and procedure (P&P) on insulin administration, and manufacturer's guideline for insulin aspart and glargine with the Director of Nursing (DON). The DON stated insulin administration sites should be rotated. The DON verified the nurses did not rotate the insulin administration sites on multiple occasions from 8/2024 to 10/2024. The DON verified the facility's P&P indicate to rotate injection sites. The DON verified the manufacturer's guideline for aspart and glargine indicated to rotate injection sites to prevent lipodystrophy and amyloidosis. The DON stated the injection sites should have been rotated to prevent lumps, bruising, and tenderness affecting the absorption of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 18 of 70 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 11/08/2024 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure services provided by the facility were provided by qualified persons in accordance with the resident's plan of care for one of two sampled residents (Resident 52) investigated under the dignity care area when Activities Assistant (AA) 1 provided hydration to Resident 52. Residents Affected - Few This failure had the potential to result in Resident 52 aspirating (accidental breathing in of food or fluid into the lungs) during the intake of fluid provided by an unqualified staff member. Findings: During a review of Resident 52's admission Record, the admission Record indicated the facility originally admitted Resident 52 on 8/24/2018 and readmitted the resident on 9/8/2020 with diagnoses including dementia (a progressive state of decline in mental abilities) and dependence on wheelchair. During a review of Resident 52's Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2024, the MDS indicated Resident 52 had short-term and long-term memory problems and severe daily decision-making impairment, and required maximal assistance or was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers. During a review of Resident 52's History and Physical (H&P), dated 7/2/2024, the H&P indicated Resident 52 has fluctuating capacity to understand and make informed decisions. During a review of Resident 52's Order Summary Report, dated 10/12/2023, the Order Summary Report indicated Resident 52 was ordered snacks three times a day for supplements. During a review of Resident 52's Care Plan titled, [Resident 52] requires assistance with ADL functions secondary to diagnosis: debility, dated 8/24/2018, the Care Plan indicated Resident 52 was dependent on staff to eat. The Care Plan further indicated the position responsible for the intervention are certified nursing assistants (CNA). During a concurrent observation and interview, on 11/5/2024, at 10:37 a.m., inside the small activity room, AA 1 was standing over Resident 52 while holding a cup next to the resident's face. Resident 52 drank from the cup held by AA 1. AA 1 stated he assists with providing hydration, including thickened liquids, to residents in the activities room. During an interview with the Director of Staff Development (DSD), on 11/8/2024, at 9:55 a.m., the DSD stated only CNAs and licensed nurses can assist the residents with feeding and/or drinks. During an interview with the Activity Director (AD), on 11/8/2024, at 12:17 p.m., the AD stated he was not aware that activity staff were not allowed to offer drinks to residents unless they were also a certified nursing assistant. During a concurrent interview and record review with the Director of Nursing (DON), on 11/8/2024, at 1:52 p.m., Resident 52's Care Plan titled, [Resident 52] requires assistance with ADL functions secondary to diagnosis: debility, dated 8/24/2018, was reviewed and the DON confirmed CNAs were responsible for assisting with feeding. The DON stated it should be the assigned staff according to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 19 of 70 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 11/08/2024 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 0659 Level of Harm - Minimal harm or potential for actual harm care plan that carries out interventions. The DON stated assisting with drinking is included as part of feeding. The DON stated residents in the small activities room have different fluid consistencies with the drinks they are provided. The DON further stated the residents need someone who is trained and qualified to assist the residents with feeding and if the staff is not qualified, there is a potential for the staff to be unaware if the resident is aspirating or not. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Feeding, Meals, Assisting Residents with, last reviewed 7/19/2024, the P&P indicated each resident receives assistance per individual resident need. The P&P further indicated the responsible discipline are the CNAs. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated the comprehensive person-centered care plan will identify the professional services that are responsible for each element of care. During a review of the facility document titled, Job Description: Activities Assistant, dated and signed by AA 1 on 3/3/2022, the facility document indicated essential job duties include following the facility policies and procedures and non-essential duties include observing residents in the dining room as assigned. The facility document did not indicate to feed residents as part of their essential and non-essential duties. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 20 of 70 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 11/08/2024 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for three (3) of five (5) sampled employees (Activity Assistant 1 [AA1], Certified Nursing Assistant 3 [CNA 3], CNA 4) during a review of employee files under Sufficient and Competent Nurse Staffing care area. This deficient practice had the potential of delayed provisions of emergency care for current residents who wishes to have full treatment in a life-threatening situation. Findings: During a record review of employee files on [DATE] at 9:55 a.m., with the Director of Staff Development (DSD), the employee files of AA1, CNA 3, and CNA 4 indicated their basic life support (BLS, a set of essential emergency procedures designed to sustain life in victims experiencing cardiac arrest) Provider Card certification from National CPR Foundation, dated [DATE] for AA 1, [DATE] for CNA 3, and [DATE] for CNA 4, indicated, the mentioned student is now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the Terms and Conditions of National CPR Foundation (NCPRF). Valid for 2 Years. During an interview on [DATE] at 10:20 a.m., AA 1 verified that the CPR training dated [DATE] was an online training. AA 1 stated participants were just given a lecture and shown videos in different ways how to perform CPR in infants, children, and adults and when a person is in danger due to choking. AA 1 stated, there was no hands-on training provided to participants. AA 1 stated the last time he took an in-person CPR training was [DATE]. During a review of the facility-provided job description for Activities Assistant (AA) form, undated, the form indicated to follow the facility policies and procedures as one of the essential job duties. During a review of the facility-provided job description for CNA form, undated, the form indicated to follow all established P&P, to include nursing procedures, safety regulations, and personnel policies as one of the major duties and responsibilities as a CNA. During a follow-up interview on [DATE] at 12:00 p.m. with AA 1, AA 1 stated he was not aware CPR training should be hands-on or in-person training from ARC/AHA. AA 1 stated hands-on training in performing CPR during emergency is important so the staff would feel confident or competent and effective in performing CPR. During a concurrent interview and record review on [DATE] at 3:30 p.m. with the DSD, the DSD stated he was previously made aware hands-on training was not required or obtaining CPR training from ARC/AHA. The DSD verified the facility policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, indicated CPR certification should be obtained and/or maintained thru ARC/AHA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 21 of 70 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 11/08/2024 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. The DSD stated the facility did not follow the P&P regarding CPR certification. During a concurrent interview and record review on [DATE] at 3:00 p.m., reviewed AA and CNA job descriptions and the facility P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, with the Director of Nursing (DON). The DON stated all staff whether licensed on non-licensed are required to have CPR certification. The DON stated CPR initial certification and recertification should be in-person and includes hands-on training for all staff from a certified instructor thru ARC/AHA. The DON verified the P&P indicated CPR certification should be obtained and/or maintained thru ARC/AHA for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. The DON stated the staff did not follow the facility P&P to maintain or obtain CPR certification thru ARC/AHA certified providers to prevent delay in performing CPR in emergency situations. The DON stated, as indicated in the job description, AA 1, CNA 3, and CNA 4 should have followed the facility P&P to maintain their CPR certification thru ARC/AHA certified provider so they would competent and effective in performing CPR in emergency situations. During a review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, last reviewed [DATE], the P&P indicated a policy statement that personnel have completed training on the initiation of to obtain and/or maintain ARC or AHA certification in CPR for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 22 of 70 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 11/08/2024 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** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four sampled residents (Residents 17 and 57) investigated under accidents by: 1. Failing to ensure Resident 17's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have the wheelchair and overbed table on top of it. 2. Failing to ensure Resident 17's floor mat was placed properly as indicated in the application instructions. 3. Failing to ensure Resident 57's floor mat did not have a medical equipment on top of it observed multiple times. These deficient practices increased the risk of Resident 17 and Resident 57 incurring an injury such as falls with fracture (a break or crack in a bone) and even death. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated the facility admitted the resident on 3/25/2014 and readmitted on [DATE] with diagnoses dementia (a progressive state of decline in mental abilities), abnormalities of gait and mobility, and muscle wasting and atrophy (the wasting away or shrinkage of an organ or tissue due to lack of use or aging). During a review of Resident 17's History and Physical (H&P), dated 7/19/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions. During a review of Resident 17's Fall Risk Evaluations, dated 4/11/2024, 7/9/2024, and 10/7/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, and chair bound. During a review of Resident 17's Care Plan (CP) addressing the resident's risk for fall due to needs assistance with transfers and ambulation related to gait/balance problems initiated 4/15/2015 last revised 2/23/2022, the CP indicated the use of floor mats at the sides of the bed as an intervention in resolved status on 3/13/2017. During a review of Resident 17s Minimum Data Set (MDS - a federally required assessment tool), dated 10/7/2024, the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS indicated Resident 17 required maximal to total assistance from staff on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 17's Physician's Orders (PO), the PO did not indicate an order for the use of floor mat. During a concurrent observation and interview on 11/5/2024 at 10 a.m. inside Resident 17's room with Certified Nursing Assistant 4 (CNA 4), observed Resident 17's wheelchair and overbed table placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 23 of 70 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 11/08/2024 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 on top of the left side floor mat, and the sign on the floor mat, This Side Down, was facing up. CNA 4 verified the floor mat was not placed correctly as indicated in the sign. CNA 4 stated the side facing up should have been facing the floor as it can cause a slip and fall accident. CNA 4 stated they always place the wheelchair and overbed table on top of the floor mats. When CNA 4 moved the wheelchair and overbed table off the floor mat, CNA 4 verified the indentation left by the wheelchair and overbed table. CNA 4 stated the purpose of the floor mat is to protect the resident in case of a fall. CNA 4 stated the floor mat gets thinner if the wheelchair and table stays on top of the floor mat for a long time and lessens the protection for the resident in case of a fall. CNA 4 the wheelchair and overbed should have not been left on top of the floor mat. CNA 4 stated Resident 17 can get injured when the resident tries to get out of bed, loose balance, and hit the wheelchair or table placed on top of the floor mat. During a concurrent observation and record review on 11/7/2024 at 3:50 p.m., inside Resident 17's room with Registered Nurse 2 (RN 2) reviewed a photo of Floor Mat 1 (FM 1) taken on 11/5/2024 at 10:00 a.m. RN 2 verified Resident 17 had floor mat on the left of the bed with the wheelchair left on top. RN 2 verified the sign on the photo indicated, This Side Down, and should have been placed correctly as indicated on FM 1. RN 2 stated the wheelchair and overbed table should not have been placed on top of the floor mat as the resident can get injured in case of a fall. RN 2 stated the floor mat is used on residents who are high risk for falls by lessening the impact of a fall. RN 2 stated leaving the wheelchair and table on top of the floor for a long time defeats the purpose of using the floor mat and can cause injury to the resident during a fall. RN 2 stated not placing the floor mat with the label facing the floor can potentially cause a slip and fall accident which may lead to injuries. During a concurrent interview and record review on 11/8/2024 at 2;55 p.m., reviewed the facility provided FM 1 Application Instructions, photo of FM 1 taken on 11/5/2024 at 10:00 a.m., and facility policy and procedures (P&P) titled, Safety and Supervision of Residents, and Hazardous Areas, Devices, and Equipment, with the Director of Nursing (DON). The DON stated the floor mats are used to minimize injuries to the resident in case of a fall. The DON stated the wheelchair and table should not be placed or left for an extended period as it defeats the purpose of placing a floor mat for resident safety placing the resident at risk for injury. The DON verified FM 1 was placed incorrectly as indicated in the photo. The DON stated FM 1 application instruction indicated the non-skid bottom helps prevent slipping when stepping into the cushion and to make sure the This Side Down label is facing the floor. The DON stated Resident 17 can slip and get injured if FM 1 label was not facing the floor. During a review of the facility provided Floor Mat 1 (FM 1) Application Instructions, dated 7/30/2024, the FM 1 indicated: FM 1 helps to minimize injuries from a fall. The FM 1 indicated the foam creates a low profile that is easy for patients to step on and off. The non-skid bottom helps prevent slipping when stepping onto the cushion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 24 of 70 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 11/08/2024 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 Make sure the This Side Down label is facing the floor. Level of Harm - Minimal harm or potential for actual harm Inform resident and staff to take care when stepping on or off the cushion to avoid tripping. Residents Affected - Some During a review of the facility policy and procedure (P&P) titled, Falls - Clinical Protocol/Interventions, last reviewed 7/19/2024, the P&P indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. During a review of the facility's P&P titled, Safety and Supervision of Residents, last reviewed 7/19/2024, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities. During a review of the facility's P&P titled, Hazardous Areas, Devices, and Equipment, last reviewed 7/19/2024, the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. b. During a review of Resident 57's admission Record (AR), the AR indicated the facility originally admitted the resident on 12/6/2022 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side and right dominant side, dementia, and history of falling. During a review of Resident 57's History and Physical (H&P), dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 57's Fall Risk Evaluation, dated 10/25/2024, the Fall Risk Evaluation indicated the resident had one to two falls in the past three months, was chair bound and required assistance with elimination. During a review of Resident 57's Care Plan (CP) addressing the resident at risk for fall, dated 10/29/2024, the CP indicated the resident with interventions including applying floor mat on both sides of the bed as ordered to decrease injury in the event of a fall. During a review of Resident 57's MDS, dated [DATE], the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident required staff assistance on mobility and ADLs. During an observation on 11/5/2024 at 8:39 a.m., inside Resident 57's room, observed bilateral floor mats by resident's bed and a wheelchair sitting on top of Resident 57's left side floor mat. During an observation on 11/5/2024 at 10:21 a.m., inside Resident 57's room, observed Resident 57 lying in bed, floor mats placed on both sides of the resident's bed, and noted a wheelchair placed on the resident's left side of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 25 of 70 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 11/08/2024 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 11/5/2024 at 10:28 a.m., inside Resident 57's room, with CNA 1, CNA 1 stated the wheelchair placed on top of Resident 57's left side floor mat belongs to Resident 38. CNA 1 stated she and another CNA have tried before to clear the resident's floor mat with Resident 38's wheelchair, but Resident 38 and does get angry if his wheelchair was moved so she keeps it there all the time. CNA 1 stated the wheelchair should be off the floor mat because it is used to prevent injury if the resident falls out of bed. When asked if the floor mat would be effective in breaking the resident's fall if the wheelchair was kept on top of it, CNA 1 stated she does not know. During a concurrent observation and interview on 11/6/2024 at 1:04 p.m., inside Resident 57's room, with the Director of Nursing (DON), the DON stated Resident 38's wheelchair was on top of Resident 57's left side floor mat. During a follow-up interview on 11/6/2024 at 1:12 p.m., with the DON, the DON stated the floor mats are used to minimize injury for fall. The DON stated the wheelchair should be removed because it would defeat the function of the floor for the resident's safety placing the resident at risk for injury. During a review of Floor Mat 1 (FM 1) Application Instructions, dated 7/30/2024, the FM 1 indicated the FM 1 helps to minimize injuries from a fall. The FM 1 indicated the foam creates a low profile that is easy for patients to step on and off. During a review of the facility policy and procedure (P&P) titled, Falls - Clinical Protocol/Interventions, last reviewed 7/19/2024, the P&P indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 26 of 70 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 11/08/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for one of one sampled residents (Resident 90) investigated under the tube feeding care area when the facility failed to replace the tubing on the tube feeding set when replacing the resident's tube feeding formula and water flush bag. This failure had the potential for clogging and harboring bacteria which may result in infection, disrupted delivery of proper nutrition and hydration, and risk for aspiration (happens when food or liquid enters a person's airway by accident when food or liquids come back up from the stomach) if the formula flows improperly. Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility originally admitted Resident 90 on 2/22/2024 and readmitted the resident on 9/15/2024 with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool), dated 10/11/2024, the MDS indicated Resident 90 had difficulty understanding and making decisions, required moderate to maximal assistance or was dependent on facility staff for activities of daily living such as eating, hygiene, dressing, showering/bathing, and surface-to-surface transfer, and received tube feeding. During a review of Resident 90's History and Physical (H&P), dated 9/15/2024, the H&P indicated Resident 90 does not have the capacity to understand and make decisions. During a review of Resident 90's Order Summary Report, dated 9/15/2024, the Order Summary Report indicated every shift Jevity 1.5 (brand name of a tube feeding formula) at 65 milliliters (ml, a unit of measure for volume) per hour via pump for 20 hours to provide 1300 ml per 1950 kilocalories (kcals, a unit of measurement for energy that is often used in nutrition and exercise) per day, turn pump on at 2 p.m. for 20 hours, may turn pump off for activities of daily living and/or other treatments, and continue feeding until dose limit is met. During a review of Resident 90's Care Plan titled, Needs tube feeding due to: Impaired swallowing poor oral intake, dated 7/2/2024, the Care Plan indicated to change feeding and tubing as ordered and flush gastrostomy tube with water ordered. During a concurrent observation and interview with Registered Nurse (RN) 1, on 11/5/2024, at 10:07 a.m., inside Resident 90's room, a container of tube feeding formula, dated 11/4/0224, and timed 6:10 a.m., and a bag containing clear liquid, dated 11/3/2024, and timed 2:00 p.m., hung on a pole next to Resident 90's bed. The tube feeding formula and bag containing clear liquid was attached to tubing that ran through a tube feeding pump and connected to Resident 90's gastrostomy tube. RN 1 stated the tube feeding formula was not changed after 24 hours of being hung and should be changed every 24 hours because the tube feeding formula could potentially expire and cause potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 27 of 70 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 11/08/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gastrointestinal issues for the resident. RN 1 stated the bag containing clear liquid was water and the bag was not changed after 24 hours of being hung and should be changed every 24 hours to provide fresh water to the resident and prevent potential gastrointestinal problems. During an interview with RN 5, on 11/8/2024, at 9:14 a.m., RN 5 stated tube feeding formula should be replaced once the ordered dose is completed. RN 5 stated when the tube feeding formula is replaced, the entire tubing set should be changed. RN 5 stated the water bag is part of the tube feeding set and cannot be removed or replaced separately from the tube feeding set. RN 5 stated if a water bag indicated a date two days prior, there is a potential the entire tube feeding set was not replaced when the formula was replaced. RN 5 further stated if the tube feeding set is not replaced when replacing the formula, there is a potential lapse in infection control due to the previously used tubing having residual formula from the previously hung formula. During an interview with the Director of Nursing (DON), on 11/8/2024, at 1:52 p.m., the DON stated the tube feeding set used by the facility is a closed set and the entire tube feeding set, including the water bag, should be replaced when the formula is replaced to prevent blockages in the tubing and to prevent infection because old tubing can be a potential source for infection. During a review of facility-provided document titled, [Tube Feeding] Enteral Feeding Pump Instructions for Use, dated 5/2023, the document indicated the tube feeding set should be replaced after 24 hours from initiation of feeding to ensure the pump is operating within specified parameters and prevents bacterial growth that could be a hazard to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 28 of 70 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 11/08/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for respiratory care for one of two sampled residents (Resident 13) reviewed under the Respiratory care area by failing to ensure Resident 13 received continuous administration of oxygen as ordered when the resident's oxygen tank (supplemental oxygen) was observed empty. Residents Affected - Few This deficient practice had the potential to place Resident 13 at risk for respiratory distress. Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted the resident on 2/17/2021 and readmitted the resident on 8/22/2024 with diagnoses including sick sinus syndrome (a type of heart rhythm disorder) and chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), with hypoxia (low levels of oxygen in blood). During a review of Resident 13's History and Physical (H&P), dated 8/22/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS - a federally required assessment tool), dated 8/30/2024, the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident required assistance from facility staff on activities of daily living including eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated the resident received oxygen therapy while a resident in the facility. During a review of Resident 13's Physician Orders (PO), dated 8/22/2024, the PO indicated the resident with order to administer continuous oxygen at 2 liters per minute (LPM - a unit of measure) via nasal cannula (nasal prongs)/mask to maintain oxygen saturation (amount of oxygen in the blood) above 92 percent (% - one part in every hundred). During a review of Resident 13's Care Plan (CP) addressing the resident's potentially for ineffective airway clearance, dated 8/23/2024, the CP indicated interventions including to administer medications as ordered and to monitor effectiveness of medications. During a concurrent observation and interview on 11/6/2024 at 9:10 a.m., inside dining room [ROOM NUMBER], with Registered Nurse 1 (RN 1), RN 1 stated Resident 13's oxygen tank was empty at 0. RN 1 stated she will replace Resident 13's oxygen tank. Observed Resident 13's oxygen setting at 2 liters per minutes (LPM) via nasal cannula. During an interview on 11/6/2024 at 12:54 p.m., with Registered Nurse 1 (RN 1), RN 1 stated residents with continuous oxygen order are connected to an oxygen tank before leaving their room. RN 1 stated the charge nurses are responsible in checking the oxygen tank so that the resident does not ran out of oxygen. RN 1 stated when oxygen treatment is not given continuously especially to residents who are dependent on oxygen therapy they may show a drop in their oxygen saturation and experience shortness of breath and/or respiratory complications. RN 1 stated the resident should be reassessed and should replace the oxygen tank before it ran out to maintain the resident's oxygen saturation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 29 of 70 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 11/08/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 11/6/2024 at 1:18 p.m., with the Director of Nursing (DON), the DON stated the resident should not have ran out of oxygen if the order is continuous. The DON stated when the physician order is not followed the resident could potentially drop in their oxygen level and risk for respiratory distress. During a review of the facility policy and procedure (P&P) titled, Oxygen Therapy, last reviewed 7/19/2024, the P&P indicated it is the policy of the facility that oxygen therapy is administered as ordered by the physician. Event ID: Facility ID: 055002 If continuation sheet Page 30 of 70 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 11/08/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review the facility failed to assess the medical need, evaluate the risks of entrapment (a state in which a person is trapped by the bed rail [also known as side rails, a type of safety device that can be attached to a bed frame to help prevent falls and provide support for getting in and out of bed] in a position that they cannot move from), and obtain a physician's order and informed consent from the resident or resident representative for one (1) out of 1 sampled resident (Resident 17) investigated under the Accidents care area. This deficient practice placed the resident at risk for potential accidents such as a body part being caught between the rails; falls if a resident attempts to climb over, around, between, or through the rails; restriction of resident's freedom of movement; decline in physical functioning; psychosocial harm; and death of residents. Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2014 and readmitted in the facility on 5/10/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), abnormalities of gait and mobility, epilepsy (a long-term brain condition where a person has repeated seizures [a sudden uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 17's History and Physical (H&P) dated 7/19/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions. During a review of Resident 17's Fall Risk Evaluations, dated 4/11/2024, 7/9/2024, and 10/7/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, and chairbound. During a review of Resident 17's Care Plan addressing the resident's risk for fall due to possible repeat episodes of seizure, initiated on 11/30/2021 and last revised on 1/16/2024, the Care Plan indicated both upper &frac14; side rails up and padded when in bed as one of the interventions to prevent traumatic injuries and manage seizure activity. During a review of Resident 17s Minimum Data Set (MDS-a resident assessment tool), dated 10/7/2024, the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS indicated the resident required maximal to total assistance from staff on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 17's Physician's Orders, the Physician's Orders dated 10/30/2024 indicated both upper one fourth (1/4 - a unit of measurement) padded side rails up when in bed to aid in mobility and positioning and for seizure precaution. During a review of Resident 17's informed consent dated 10/30/2024, the informed consent indicated bilateral &frac14; siderails up while in bed for mobility and positioning and for seizure precaution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 31 of 70 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 11/08/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 11/5/2024 at 10 a.m., inside Resident 17's room with Certified Nursing Assistant 4 (CNA 4), observed Resident 17 asleep in bed with both upper side rails up. CNA 4 stated she thinks the siderails were always used for the resident for safety. CNA 4 stated she was not sure if the siderails were &frac14; or one half (1/2 - a unit of measurement). CNA 4 verified there was a gap between the siderails and the mattress and Resident 17's arm can get caught in between and cause injury. During a concurrent observation and interview on 11/7/2024 at 3:50 p.m., inside Resident 17's room with Registered Nurse 2 (RN 2), RN 2 verified Resident 17 had bilateral siderails up and the current physician's order was bilateral &frac14; siderails. RN 2 verified the gap between the siderails and the mattress which can potentially trap Resident 17's arm or any part of the body and cause injury to the resident. RN 2 stated they had bed safety evaluation form but not sure if the evaluation included assessment for risk of entrapment. During a concurrent observation and interview on 11/8/2024 at 1:30 p.m., inside Resident 17's room with the Director of Nursing (DON), the DON verified Resident 17 had bilateral siderails up and the facility uses only &frac14; siderails up as ordered by the physician for resident safety and assists with mobility during ADL care, turning and repositioning, and as a seizure precaution. The DON stated the siderails were fixed attachment on the bed. The DON verified the gap between the mattress and the siderails and it can potentially cause injury when Resident 17's arm or any part of the body gets caught on the gap. During a follow up concurrent interview and record review on 11/8/2024 at 3:00 p.m., reviewed facility-provided Bed Frame 1 (BF 1) User and Care Manual, Resident 17's physician's orders, informed consent, and bed safety evaluation forms with the DON. The DON stated the user manual indicated BF 1 had photos of the three (3) types of siderails for the bed frame which includes &frac12; length siderails, 3 position pivoting assist rail, and fixed assist rails. The DON stated based on the previous observation of Resident 17's siderails, Resident 17 had &frac12; length siderails. The DON stated the facility should have obtained a physician's orders and informed consent from the resident or responsible party indicating the use of bilateral &frac12; siderails up while in bed instead of &frac14; siderails to ensure they were aware of the current plan of care as well as the risks and benefits of the use of &frac12; length siderails including risk of entrapment. The DON verified the bed safety evaluation forms dated 10/7/2024 and 10/19/2024 did not indicate an assessment for the risk of entrapment and least restrictive measures attempted prior to use of the &frac12; length siderail. The DON stated the continued use of the &frac12; length siderails without appropriate assessment resulted in inappropriate use predisposing resident to injury such as entrapment. During a review of the facility-provided BF 1 User Care and Manual, undated, the manual indicated the following: Use only the proper size mattress that will minimize the gap between the side of the mattress and the side rails. The gap must be small enough to the prevent the patient from getting caught. Always evaluate patients for guard against patient risk of side rail entrapment in accordance with medical protocols. Failure to do so could result in injury and/or death. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 32 of 70 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 11/08/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, last reviewed 7/19/2024, the P&P indicated: Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails. b. The resident's risk from the use of bed rails and how these will be mitigated. c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident. The use of bed rails or side rails is prohibited unless the criteria for use of bed rail rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 33 of 70 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 11/08/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Residents 22) was free from unnecessary medications by not: Residents Affected - Few 1. Assessing Resident 22's pain level prior to administering Celebrex (a medication referred to as analgesic which is used to decrease pain) on 11/5/2024, 2. Administering Celebrex to Resident 22 daily for a documented pain level of zero (0) (by using a numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) between 11/1/2024 and 11/5/2024, and 3. Following physician orders for non-pharmacological (also known as non-drug, that do not involve medications or drugs) interventions prior to the administration of Celebrex to Resident 22. As a result, Resident 22 received Celebrex daily between 11/1/2024 and 11/5/2024 against physician order and without adequate assessment and monitoring for pain. This failure had the potential to cause Resident 22 to receive suboptimal (less than the highest standard or quality) care due to not assessing the need and effectiveness of Celebrex, leading to the use of unnecessary medication, potentially increasing the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) such as gastrointestinal (GI - relating to the stomach) bleeding, pain, diarrhea, vomiting, fever, and nausea, negatively impacting the physical, mental, and psychosocial well-being of Resident 22. Findings: During a review of Resident 22's admission Record (a document containing demographic and diagnostic information,) dated 11/5/2024, the admission Record indicated Resident 22 was originally admitted to the facility on [DATE] and readmitted the resident on 10/2/2015 with diagnoses including osteoarthritis (breakdown of bone causing pain and stiffness.) During a review of Resident 22's Order Summary Report, dated 11/5/2024, the Order Summary report indicated Resident 22 was prescribed the following: Celebrex 200 milligram ([mg] - a unit of measure of mass) to give one capsule by mouth one time a day for 4 - 6 moderate pain. Give after meals. Chart non-drug intervention/s done as follows: (1) relaxation (2) redirect (3) backrub (4) reposition (5) rest (6) other, prior to Pro Re Nata ([PRN] - as needed) analgesic use. If ineffective give medication as ordered, starting 6/20/2024. During a review of Resident 22's Medication Administration Record ([MAR] - a record of medications administered to residents) for November 2024, the MAR indicated Resident 22 was prescribed the following: Celebrex 200 mg to give one capsule by mouth one time a day for 4 - 6 moderate pain. Give after meals. Chart non-drug intervention/s done as follows: (1) relaxation (2) redirect (3) backrub (4) reposition (5) rest (6) other, prior to PRN analgesic use. If ineffective give medication as ordered, daily at 9 a.m. The MAR indicated that between 11/1/2024 and 11/5/2024 Resident 22's pain level was documented zero (0) and Celebrex was administered daily at 9 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 34 of 70 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 11/08/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/5/2024 at 9:33 a.m., in Medication Cart Station 2, Registered Nurse (RN) 3 was observed administering Celebrex 200 mg capsule to Resident 22. Resident 22 was observed swallowing the Celebrex capsule whole with water. RN 3 was observed not asking Resident 22 whether Resident 22 had pain and what the pain level was. During an interview and concurrent review of Resident 22's MAR on 11/5/2024 11:49 a.m. with RN 3, RN 3 stated that if Resident 22 did not have pain that was moderate between 4 and 6 that Resident 22 should not be administered Celebrex, according to the physician order. RN 3 stated that RN 3 failed to assess Resident 22's pain level and administered Celebrex 200 mg capsule to Resident 22 on 11/5/2024 at 9:33 a.m. without knowing if Resident 22's pain level was moderate between 4 and 6. RN 3 stated that RN 3 administered Celebrex against the physician order, did not follow the directions for non-drug interventions, and documented the MAR that Resident 22 had a pain level of zero (0) on 11/5/2024. RN 3 stated that the MAR indicated that Resident 22 had a pain level of zero (0) and received Celebrex 200 mg every day between 11/1/2024 and 11/5/2024. RN 3 stated that Celebrex could cause GI irritation and Resident 22 may be receiving Celebrex unnecessarily without being assessed and monitored for pain and placed at and increased risk of having adverse effects. During an interview on 11/7/2024 at 12:57 PM, with the Director of Nursing (DON,) the DON stated that Resident 22 was prescribed Celebrex 200 mg daily for moderate pain between 4 and 6 and when non-drug interventions did not improve the pain. The DON stated if Resident 22 did not have moderate pain between 4 and 6 after non-drug intervention that Resident 22 should not be administered Celebrex. The DON stated that RN 3 failed to assess Resident 22's pain and follow physician orders for non-drug intervention, prior to administering Celebrex 200 mg on 11/5/2024 at 9:30 AM. The DON stated it was unnecessary to administer Celebrex to Resident 22 for pain level of zero (0) or without non-drug interventions or assessment of pain. The DON stated that using Celebrex unnecessarily placed Resident 22 at risk for developing GI adverse effects. The DON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and not to place residents at risk of administering unnecessary medications that could result in adverse effects, negatively impacting their health and well-being. During a review of the facility's policy & procedures (P&P), titled Administering Medications, last reviewed 7/19/2024, the P&P indicated that Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders . 8. The following information must be checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. During a review of the facility's P&P, titled Pain Assessment and Management, last reviewed 7/19/24, the P&P indicated that The purpose of this procedure are to help the staff identify pain in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 35 of 70 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 11/08/2024 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 0757 resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Level of Harm - Minimal harm or potential for actual harm General Guidelines Residents Affected - Few 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . Steps in Procedure 4. Ask the resident if he/she is experiencing pain. Implementing Pain Management Strategies 2. Pharmacological (related to drugs) interventions (i.e. analgesics) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident. 6. implement the medication regimen as ordered . Documentation 1. Document the resident's reported level of pain with adequate detail. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 36 of 70 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 11/08/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** a.2. During a review of Resident 37's admission Record (a document containing demographic and diagnostic information,) dated 11/7/24, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus 2 ([DM2] - a condition where there are high blood sugar levels.) Residents Affected - Some During a review of Resident 37's Order Summary Report, dated 11/7/24, indicated Resident 37 was prescribed Novolog (fast-acting insulin) to inject per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) subcutaneous ([SQ] - under the skin) before meals and at bedtime, starting 5/16/24. During a review of Resident 37's Medication Administration Record ([MAR] - a record of medications administered to residents), for November 2024, the MAR indicated Resident 37 was prescribed Novolog per sliding scale SQ before meals and at bedtime, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. During the same review, the MAR indicated Novolog SQ was administered by the following licensed nurses, on the following days, times, and sites: 11/6/24 four (4) units ([un] - a measure of dosage for insulin) at 11:30 a.m. on Left Upper Quadrant ([LUQ] upper left side of abdomen) by Licensed Vocational Nurse (LVN) 3 11/6/24 six (6) un at 4:30 p.m. on LUQ by LVN 4 a.3.During a review of Resident 56's admission Record dated 11/6/24, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM2. During a review of Resident 56's Order Summary Report, dated 11/6/24, indicated Resident 56 was prescribed Fiasp (rapid-acting insulin) to inject per sliding scale SQ before meals and at bedtime related to DM2, starting 3/22/24. During a review of Resident 56's MAR for November 2024, the MAR's indicated Resident 56 was prescribed Fiasp to inject per sliding scale SQ before meals and at bedtime related to DM2, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. During the same review, the MAR indicated Fiasp SQ was administered by the following licensed nurses, on the following days, times, and sites: 11/4/24 two (2) un at 9 p.m. on left arm by Registered Nurse (RN) 4 11/5/24 two (2) un at 11:30 a.m. on left arm by RN 3 a.4. During a review of Resident 60's admission Record dated 11/6/24, indicated the resident was originally admitted to the facility on [DATE] with a diagnosis including DM2. During a review of Resident 60's Order Summary Report, dated 11/6/24, indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM2, starting 8/9/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 37 of 70 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 11/08/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 60's MAR for November 2024, the MAR indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM2, at 6:30 a.m. During the same review, the MAR indicated Lantus SQ was administered by the following licensed nurses, on the following days, times, and sites: Residents Affected - Some 11/2/24 five (5) un at 6:30 a.m. on Right Lower Quadrant ([RLQ] - lower right side of abdomen) by LVN 5 11/3/24 five (5) un at 6:30 a.m. on RLQ by LVN 5 During a concurrent interview and record review on 11/7/24 at 12:57 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 37's, 56's and 60's MAR for November 2024. The DON stated that for Resident 37, 56 and 60 the MARs indicated there were instances where the insulin administration sites were not rotated by several licensed nurses, as expected by facility policy, standard of practice and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 37, 56 and 60 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites. The DON stated not rotating insulin administration sites was considered a significant medication error. During a review of the facility's policy & procedures (P&P,) titled Adverse consequences and Medication Errors, last reviewed 7/19/24, the P&P indicated: 2. An 'adverse consequence' is defined as an unpleasant symptoms or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a. adverse drug/medication reaction 3. An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug . 4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 38 of 70 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 11/08/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 5. Residents Affected - Some Examples of medication error include: h. Failure to follow manufacturer instructions and/or accepted professional standards. During a review of facility's P&P titled, Insulin Administration, last reviewed 7/19/24, indicated: To provide guidelines for the safe administration of insulin to residents with diabetes. 3. The type of insulin, .and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. 16.b. injection sites should be rotated, preferably within the same general area. During a review of facility-provided manufacturer's guide Instructions for Use for Fiasp, dated September 2017, the guide indicated to Change (rotate) your injection sites for each injection. Do not use the same injection site for each injection. During a review of facility-provided manufacturer's guide Instructions for Use for Novolog, dated February 2023, the guide indicated to If you inject Novolog, change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) at the injection sites. Do not use the same injection site for each injection. Do not inject where the skin has pits, is thickened, or has lumps. Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin. During a review of manufacturer's guide for Injecting Lantus with a vial and syringe, dated 2022, the guide indicated to Change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged. During a review of facility-provided manufacturer's guideline on insulin glargine, last revised 6/2022, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia (low blood sugar), allergic reactions, injection site reactions, lipodystrophy, pruritus (itchiness), rash, edema (swelling), and weight gain. During a review of facility-provided manufacturer's guideline on insulin aspart, last revised 2/2023, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, and weight gain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 39 of 70 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 11/08/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four (4) of five (5) sampled residents (Resident 14, 37, 56 and 60) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. The deficient practice increased the risk that Residents 14, 37, 56 and 60 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F658 Findings: a.1. During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2024 with diagnoses including type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar in the blood to become too high), chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly which results in a buildup of excess fluid and waste in the body), and obesity (a condition that occurs when a person has abnormal or excessive fat accumulation that presents a risk to health). During a review of Resident 14's History and Physical (H&P) dated 7/10/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/24/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with eating and assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 14 had a diagnosis of DM 2 and received insulin. During a review of Resident 14's Order Summary Report, the Order Summary Report indicated the following physician's order: - 7/10/2024: insulin aspart (a fast-acting insulin used to treat high blood sugar that starts to work about 15 minutes after injection) injection solution 100 unit per milliliter (unit/ml - a unit of measurement) inject five (5) units SQ before meals and at bedtime for DM 2 hold if blood sugar (BS) less than (< - a unit of measurement) 100 or nothing by mouth (NPO). - 8/16/2024: insulin aspart injection solution 100 unit/ml inject SQ before meals and at bedtime for fingerstick blood sugar (FSBS). If BS <70 give Glucogel (a product used to treat low blood sugars absorbed through the lining of the mouth and helps increase the blood glucose within 15 minutes) 1 tube, 8 ounces (oz - a unit of measurement) orange juice or light snack if resident alert and able to take by mouth, if with altered level of consciousness give Glucagon (a hormone that increases blood sugar levels by stimulating the liver to release glucose into the bloodstream) 1 ampule (a small, sealed glass container that holds a liquid, usually a medication, that is intended to be injected) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 40 of 70 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 11/08/2024 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 0760 intramuscular (IM - injection within or into a muscle) recheck BS and call physician (MD). Level of Harm - Minimal harm or potential for actual harm - Inject as per sliding scale: if 70 - 150 = zero (0) unit; <70 = Initiate hypoglycemia (low blood sugar) protocol and call MD; 151 - 200 = two (2) units; 201 - 250 = four (4) units; 251 - 300 = six (6) units; 301 350 = eight (8) units; 351 - 400 = ten (10) units; more than (>) 400 may give 12 units and call MD, SQ before meals and at bedtime for FSBS. Residents Affected - Some - 8/16/2024: insulin glargine (a long-acting insulin used to control the amount of sugar in the blood of patients with diabetes) SQ solution 100 unit/ml inject 32 units SQ at bedtime for DM 2. During a review of Resident 14's Medication Administration Record (MAR) for 8/2024, 9/2024, and 10/2024, the MAR indicated insulin aspart and insulin glargine injection solution were administered as follows: - Insulin aspart injection solution 100 units/ml: 8/7/2024 4:30 p.m. SQ Abdomen - left lower quadrant (LLQ) 807/2024 9:00 p.m. SQ Abdomen - LLQ 8/9/2024 9:00 p.m. SQ Abdomen - right upper quadrant (RUQ) 8/10/2024 6:30 a.m. SQ Abdomen - RUQ 8/10/2024 4:30 p.m. SQ Abdomen - LLQ 8/10/2024 9:00 p.m. SQ Abdomen - LLQ 8/12/2024 11:30 a.m. SQ Arm - left 8/12/2024 4:30 p.m. SQ Arm - left 8/13/2024 11:30 a.m. SQ Arm - left 8/13/2024 4:30 p.m. SQ Arm - left 8/15/2024 11:30 a.m. SQ Abdomen - left upper quadrant (LUQ) 8/15/2024 4:30 p.m. SQ Abdomen - LUQ 8/23/2024 11:30 a.m. SQ Abdomen - RUQ 8/23/2024 4:30 p.m. SQ Abdomen - RUQ 9/13/24 6:30 a.m. SQ Abdomen - right lower quadrant (RLQ) 9/13/24 11:30 a.m. SQ Abdomen - RLQ 9/21/24 9:00 p.m. SQ Abdomen - LUQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 41 of 70 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 11/08/2024 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 0760 9/22/24 6:30 a.m. SQ Abdomen - LUQ Level of Harm - Minimal harm or potential for actual harm 9/23/24 9:00 p.m. SQ Abdomen - LUQ 9/24/24 6:30 a.m. SQ Abdomen - LUQ Residents Affected - Some 9/27/24 9:00 p.m. SQ Abdomen - RUQ 9/28/24 6:30 a.m. SQ Abdomen - RUQ 9/21/24 9:00 p.m. SQ Abdomen - LUQ 9/22/24 6:30 a.m. SQ Abdomen - LUQ 10/19/24 9:00 p.m. SQ Abdomen - LLQ 10/20/24 6:30 a.m. SQ Abdomen - LLQ 10/25/24 9:00 p.m. SQ Abdomen - RLQ 10/26/24 6:30 a.m. SQ Abdomen - RLQ 10/26/24 9:00 p.m. SQ Abdomen - RUQ 10/27/24 6:30 a.m. SQ Abdomen - RUQ 10/25/24 9:00 p.m. SQ Abdomen - RLQ 10/26/24 6:30 a.m. SQ Abdomen - RLQ -Insulin glargine injection solution 100 units/ml: 8/12/24 9:00 p.m. SQ Abdomen - RUQ 8/13/24 9:00 p.m. SQ Abdomen - RUQ 8/15/24 9:00 p.m. SQ Abdomen - LUQ 8/16/24 9:00 p.m. SQ Abdomen - LUQ 10/06/24 9:00 p.m. SQ Abdomen - RUQ 10/07/24 9:00 p.m. SQ Abdomen - RUQ During a concurrent interview and record review on 11/7/2024 at 2:45 p.m., reviewed Resident 14's physician's orders, MAR, and location of administration sites for insulin aspart and insulin glargine injection solution for 8/2024, 9/2024, and 10/2024 with Registered Nurse 2 (RN 2). RN 2 stated insulin administration sites should be rotated per standards of practice. RN 2 verified the insulin administration sites were not rotated. RN 2 stated the insulin administration sites should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 42 of 70 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 11/08/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete rotated. RN 2 stated not rotating the insulin injection site can damage the tissues such as lumps and bruising. During a concurrent interview and record review on 11/8/2024 at 3:00 p.m., reviewed Resident 14's location of insulin administration sites for insulin aspart and insulin glargine for 8/2024, 9/2024, and 10/2024, policy and procedure (P&P) on insulin administration, and manufacturer's guideline for insulin aspart and glargine with the Director of Nursing (DON). The DON stated insulin administration sites should be rotated as a standard of practice. The DON verified the nurses did not rotate the insulin administration sites on multiple occasions from 8/2024 to 10/2024. The DON verified the facility's P&P indicate to rotate injection sites. The DON stated the nurses did not follow the manufacturer's guideline and the standards of practice. The DON stated the insulin administration sites should have been rotated as it can affect the absorption of insulin and can also cause skin lumps and bruising. The DON stated not rotating insulin administration site is considered a medication error per the manufacturer's guideline and standards of practice. Event ID: Facility ID: 055002 If continuation sheet Page 43 of 70 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 11/08/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store one insulin (medication used to regulate blood sugar levels) Humalog (rapid-acting insulin) vial (a glass bottle that contains the insulin) for Resident 49, in accordance with manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart 3). This deficient practice increased the risk that Residents 49 could have received insulin that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation and a concurrent interview on [DATE] at 12:34 p.m., in Medication Cart 3, with Licensed Vocational Nurse 3 (LVN 3), Resident 49's unopened Humalog vial was found stored in a manner contrary to its manufacturer's requirements, and not labeled with an open date as required by its manufacturer's specifications and facility policy and procedures (P&P). Resident 49's unopened Humalog vial was found stored at room temperature without a date indicating when storage or use at room temperature began, with an additional white label affixed to the amber prescription bottle (where the Humalog vial is stored in) indicating to refrigerate. According to the manufacturer's product labeling, unopened Humalog vials should be stored refrigerated between 36 to 46 degrees Fahrenheit (&deg;F scale for measuring temperature) and if stored at room temperature should be discarded after 28 days. LVN 3 stated that the Humalog vial for Resident 49 was stored at room temperature, not opened, and not labeled with a date indicating when storage at room temperature began. LVN 3 stated the unopened Humalog vial should have been stored in the refrigerator as indicated by the white label affixed to the prescription bottle. LVN 3 stated that multi-dose (containing more than one dose of medication) insulin vials like Humalog needed to be labeled with a date when brought to room temperature to know when to be discarded or needed to be stored in the refrigerator until opened. LVN 3 stated it was unknown when the Humalog vial for Resident 49 was stored at room temperature therefore unknown when it would expire and should be discarded and not to be used in error. LVN 3 stated insulin vials stored at room temperature are usually good for 28 days and lose potency (effectiveness) and sterility (free from contaminants) beyond that date and considered expired. LVN 3 stated administering expired insulin will not be effective in treating residents' blood sugar levels and can harm Resident 49 by causing hyperglycemia (high blood sugar) levels, coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels), or potential injection site infections, requiring transfer to a hospital. During an interview on [DATE] at 12:57 p.m., with the Director of Nursing (DON), the DON stated that the unopened insulin Humalog vial for Resident 49 should be stored in the refrigerator or labeled with a date when it came to storage at room temperate and discarded 28 days later. The DON stated that several licensed nurses failed to refrigerate the unopened Humalog vial for Resident 49 or failed to label the vial with the date when storage at room temperature began. The DON stated without a date labeled on the vial it was unknown when the Humalog vial would expire, which can potentially lead to the administration of expired insulin to Resident 49 leading to medication errors. The DON stated that expired insulin has lost its potency (effectiveness, strength) and administering expired insulin will not be effective in controlling blood sugar levels and can harm Resident 49 by causing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 44 of 70 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 11/08/2024 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 hyperglycemia, coma, leading to hospitalization. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P, titled Storage of Medications, last reviewed [DATE], the P&P indicated: Residents Affected - Few 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. All insulin (vials/pens) expire 28 days after opening. During a review of the facility's P&P titled Medication Storage and Labeling, last reviewed [DATE], the P&P indicated: 1. Refer to Appendix D for a list of specific medications .with manufacturers' specifications for short expiration dates. 3. It will be the responsibility of the Nursing Staff to enter the opening date on all manufacturers' labels or blank pharmacy labels. During a review of the facility-provided guide titled Appendix D - Requirements for Specific Medications and Reagents, [undated], the guide indicated that Humalog insulin expiration opening was 28 days. During a review of the facility-provided guide titled Insulin Storage Recommendations at Room Temperature, [undated], the guide indicated that Humalog vial stored at room temperature was good for 28 days. During a review of the facility's P&P, titled Insulin Administration, last reviewed [DATE], the P&P indicated that: 4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening. During a review of the facility's P&P, titled Administering Medications, last reviewed [DATE], the P&P indicated that: 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 45 of 70 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 11/08/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the menu and did not meet the nutritional needs of 17 of 96 residents on puree texture diets (diet with pudding-like consistency foods used for individuals with difficulty chewing or swallowing) when: a. Polenta (a grainy dish made from boiled cornmeal) was watery and could not hold its shape on the plate on 11/5/2024 for lunch. b. Puree carrots were runny and could not hold its shape on the plate on 11/6/2024 for lunch. This failure had the potential to result in difficulty in eating, chewing, and swallowing to the residents and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss. Findings: a. During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/5/2024, the spreadsheet indicated residents on puree and International Dysphagia Diet Standardization 4 ([IDDSI] a global standard to describe texture modified foods and thickened drinks for individuals with swallowing difficulties in all ages, in all settings) Level 4 (pureed foods with extremely thick fluids) portions would get the following food items: Puree lemon chicken piccata (pan-fried chicken cutlet), half (1/2) cup (c, household measurement) Puree polenta &frac12; c Puree spinach au gratin (a baked dish of spinach covered in a cheese sauce and breadcrumbs) &frac12; c Parsley flakes Puree fresh green salad with dressing &frac12; c Puree gelatin 2.7 ounces (oz, household measurement) Milk 4 oz During an observation on 11/5/2024 at 11:05 a.m. at the trayline area (an area where foods were assembled on the trays), the puree chicken and polenta looked runny with weeping liquids. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 46 of 70 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 11/08/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for puree diet and interview on 11/05/2024 at 12:44 p.m. with the Dietary Supervisor (DS), DS stated the polenta was runny. The DS stated puree foods should hold its form on the plate and have a pudding-like consistency. The DS stated residents could have difficulty picking up runny foods with their utensils and might not eat the food causing them to lose weight as a potential outcome. During a review of the facility's standardized recipe titled RECIPE: POLENTA, dated 2024, the standardized recipe indicated 4. Polenta is done when texture is creamy, and the individual grains are tender. Pureeds/dysphagia (difficulty swallowing): Puree to ensure no lumps. Puree following the puree recipes in the Food Safety/Misc. section of Book #1. During a review of the facility's standardized recipe titled Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes, etc.), the standardized recipe indicated, The finished puree items should be smooth and free of lumps, hold it shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDSSI level 4 testing requirements. b. During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/6/2024, the spreadsheet indicated residents on puree portions would get the following food items: Pure apple glazed meat balls 2 pieces (pcs) Puree brown rice Florentine 1/3 cup (c, household measurement) Puree carrots with parsley 1/3 c Puree wheat roll &frac14; c Margarine 1 teaspoon Mousse Dessert 1/3 c, no chocolate chips Milk 4 ounces (oz, unit of measurement) During an interview on 11/06/2024 at 11:19 a.m. with Registered Dietitian (RD), RD stated puree diets was used for those residents with chewing and swallowing problems. RD stated puree food should have a texture of mashed potato and should form and hold it shape on the plate. RD stated if the puree food was runny, it could get mixed up with other food and residents would have difficulty to scoop out their food using their utensils. RD stated the cook probably added more water to the puree food and it would lessen the nutrients causing residents to lose wight as a potential outcome. RD stated standardized recipe should be followed exactly. During concurrent observation and interview on 11/6/2024 at 11:55 a.m. with RD, RD stated the carrots was a little watery for puree. During a review of the facility's standardized recipe titled Recipe: Carrots with Parsley, dated 2024, the standardized recipe indicated, Pureeds: Puree #12 scoop. Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 47 of 70 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 11/08/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Vegetables, dated 2024, the standardized recipe indicated 5. The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished puree must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt test. During a review of the facility's Diet Manual titled Regular Pureed Diet/IDDSI Level 4, dated 2024, the Diet Manual indicated, DESCRIPTION: the pureed diet is a regular diet that has been designed for residents who have difficulty chewing/and or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. During a review of the facility's policies and procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. During a review of IDSSI website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 48 of 70 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 11/08/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: Residents Affected - Some a. The polenta (a grainy dish made from boiled cornmeal) was watery, runny, and touching other foods on the plate for Resident 10. b. Fresh green salad with dressing was served frozen and wilted for Resident 10. These failures had the potential to result in 95 of 96 facility residents getting food from the kitchen, including Resident 10 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on 3/11/2010 and readmitted the resident on 5/19/2024 with diagnoses including chronic kidney disease ([CKD] a long term condition where the kidneys are damaged and cannot filter blood properly), Type II diabetes mellitus ([DM 2] a chronic disease that occurs when the body does not produce enough insulin (hormone that lowers the level of glucose [sugar] in the blood) or does not use it properly, resulting in high blood sugar levels) and dysphagia (difficulty swallowing). During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 9/18/2024, the MDS indicated Resident 10 was moderately intact (process of thinking and reasoning) with daily decision making. The MDS indicated Resident 10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) and assistance throughout or intermittently when eating. During a review of Resident 10's Order Summary Report, dated 5/19/2024, the Order Summary Report indicated Resident 10 was ordered a consistent carbohydrate ([CCHO] a therapeutic diet with the same amount of carbohydrates per meal that helps control blood sugar levels), no added salt ([NAS] no salt packet served on the tray) with regular liquid (fluids with no restriction) consistency. During a concurrent observation and interview on 11/6/2024 at 12:40 p.m. with Resident 10, it was observed that the salad looked wilted, and the polenta was runny on the plate. Resident 10 stated he did not like the food and did not like the way how it looked. Resident 10 stated he could did not even know what the food was. During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/5/2024, the spreadsheet indicated residents on regular diet (diet with no restriction) would get the following food items: Lemon chicken piccata (pan-fried chicken cutlet), 3 oz (oz, unit measurement) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 49 of 70 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 11/08/2024 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 0804 Polenta half (&frac12;) cup (c, household measurement) Level of Harm - Minimal harm or potential for actual harm Spinach au gratin (a baked dish of spinach covered in a cheese sauce and breadcrumbs) &frac12; c Parsley flakes Residents Affected - Some Fresh green salad with dressing &frac12; c Gelatin 2.7 oz with whip topping 1 tablespoon. Milk 4 oz During a concurrent observation and interview on 11/5/2024 at 12:27 p.m., of the test tray (a process of tasting, temping, and evaluating the quality of food) with the Dietary Supervisor (DS), the DS stated the polenta was watery and runny. The DS stated the salad was frozen and the tray was not presented well as the polenta was touching other food items on the plate. The DS stated frozen salad could lose its nutrients and change its flavor. The DS stated a good tray presentation enhanced residents to eat. The DS stated residents would not eat the food resulting to weight loss as a potential outcome for the residents. During an interview on 11/06/2024 at 11:19 a.m. with the Registered Dietitian (RD), the RD stated the standardized recipes must be followed for the food to looked appetizing and so that food would not change its flavor. The RD stated residents would not have an appetite because the food did not look good resulting to weight loss as a potential outcome. During a review of the facility's policies and procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 50 of 70 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 11/08/2024 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen when: Residents Affected - Some a. Garbanzo (chickpea) salad and sherbert were not labeled with product names. b. Three eggs and hash brown (staff food) in a Styrofoam container was sitting on the countertop by the thawing spinach container. c. Staff walked around inside the walk-in refrigerator while drinking from an open coffee tumbler. d. Domes and pans were stacked wet. e. Ice machine internal parts had brown and black slimy dirt when wiped with paper towel. f. Internal parts of the mixer had dry food residues and buildup. g. Staff's cellphone was stored on top of the pot in the clean area. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 95 of 96 medically compromised residents who received food and ice from the kitchen. Findings: a. During an observation on 11/5/2024 at 8:14 a.m. of the reach-in freezer, frozen items had no product name label. During an observation on 11/5/2024 at 8:20 a.m., in the walk-in refrigerator, prepared food item had no product name label. During a concurrent observation and interview on 11/05/2024 at 8:34 a.m. with Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS), DS stated their process of labeling food was, once the food was opened, the staff had to cover it, label it with open date, expiration dates and the name of the food item. DS stated the prepared food item was not labeled with name. ADS stated the prepared food item was pinto beans but had to double check and it was garbanzo beans. DS stated the ice cream and sherbert individually portioned on dishes were not labeled with product names. DS stated the staff must label the food with the product name so that staff were aware what they were serving the residents. DS stated if food items were not labeled with name, the wrong food could be given to residents and could cause allergic reactions to some residents who had allergies as a potential outcome. During a review of facility's Policies and Procedures (P&P) titled, Labeling and Dating of Foods, dated 7/19/2024, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer needed to be labeled and dated. All prepared food needed to be covered, labeled, and dated. Items can be dated individually or in bulk on a tray with masking tape if going to be used for meal service (i.e. salads, drinks, and other miscellaneous items for tray line). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 51 of 70 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 11/08/2024 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 During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. b. During an observation on 11/5/2024 at 8:19 a.m. in the preparation area where spinach was thawing, there was a Styrofoam bowl container with three boiled eggs and one hash brown near the thawing spinach. During an interview on 11/5/2024 at 8:51 a.m. with DS, DS stated the Styrofoam bowl container with eggs and hash brown were food from the tray line for [NAME] 1's breakfast and it should not be in the preparation area as it could cause cross-contamination. During a review of facility's P&P titled, Employee Meals, dated 7/19/2024, P&P indicated, POLICY: Food brought by employees outside the facility shall not be kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen. All containers should be labeled with employee's name and the date it was brought in. c. During an observation on 11/5/2024 at 8:20 a.m. near the walk-in freezer, a staff walked around while drinking coffee from a coffee tumbler without a cover. During an interview on 11/5/2024 at 8:42 a.m. with DS, DS stated staff could not eat in the working area and they could not bring drinks in the kitchen unless it was covered. DS stated staff needed to go to the lunch area to eat and drink. DS stated staff went in the walk-in refrigerator and got some milk and the coffee tumbler was not covered. DS stated walking and drinking in the walk-in refrigerator was not okay due to cross contamination. DS stated residents could have vomiting and diarrhea as a potential outcome of cross-contamination. During a review of the facility's P&P titled Employee Meals, dated 7/19/2024, the P&P indicated, Staff must eat in designated meal areas. Eating in the kitchen is not allowed. During a review of the facility's P&P titled, Cross-Contamination, dated 7/19/2024, the P&P indicated, Cross-contamination is the process by which bacteria or other microorganisms are transferred from one food to another. Hazards are present when preparing, storing, and serving foods. The residents are counting on each one of you to protect their health by proper food handling. During a review of the facility's P&P titled, Phone/Personal Belongings of Employee Storage Area, dated 7/19/2024, the P&P indicated, Not allowed activities such as eating in the kitchen production area, chewing gum, spitting, smoking, or chewing tabaco. These activities cause you to bring your hands to your mouth, thus contaminating them with saliva that contains harmful germs. During a review of Food Code 2022,, the Food Code 2022 indicated 2-401 Food Contamination Prevention. 2-401.11 Eating, Drinking, or using Tabaco Products (A) Except as specified in (B) of this section, an employee shall eat, drink, or use any form of tobacco products only in designated areas where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 52 of 70 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 11/08/2024 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 the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. (B) A food employee may drink from a closed beverage container if the container is handled to prevent contamination of: (1) the employee's hands; (2) the container; and (3) Exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Residents Affected - Some d. During an observation on 11/5/2024 at 10:58 a.m. the domes by the dishwashing area were stacked wet. During a concurrent observation and interview on 11/6/2024 at 2:55 p.m. with ADS near the three-compartment sink, ADS stated the pans were stacked wet. ADS stated it was important to air dry the pots and pans before stacking them for storage as wet pans grow bacteria when stacked wet. ADS stated residents could get sick of vomiting and diarrhea as a potential outcome. During a review of facility's P&P titled Dishwashing, dated 7/19/2024, the P&P indicated, Dishes are to be air dried in rack before stacking and storing. During a review of Food Code 2022, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. e. During an observation on 11/5/2024 at 11:09 a.m. of ice machine 2, the internal parts of the ice machine 2 had brown and black slimy dirt when wiped with paper towel. During an interview on 11/5/2024 at 11:12 a.m. with ADS, ADS stated ice machine 2 was last cleaned two months ago by an outside vendor and the staff only cleaned the external parts daily. ADS stated they used ice for nourishments and water every mealtime for residents. ADS stated ice machine 2 internal parts looked like brown and black dirt. ADS stated it was not okay for the Ice machine 2 to have dirt because residents might get sick due to the bacteria in the ice machine upon consumption of the ice. During an interview on 11/5/2024 at 11:23 a.m. with DS and Maintenance Supervisor (MS), DS stated maintenance personnel was responsible for cleaning ice machine 2. MS stated the last time Ice machine 2 was last cleaned last Saturday. DS stated it was not okay for the ice machine to have dirt as residents could have food borne illnesses after consuming ice as a potential outcome. During a review of the facility's vendor invoice titled, Invoice, dated 9/16/2024, the invoice indicated ice Machines 1 and 2 were cleaned by an outside vendor on 9/16/2024. During a review of facility's P&P titled, Ice Machine Cleaning Procedures, dated 7/19/2024, the P&P indicated, POLICY: The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. Procedure: Clean inside of ice machine with sanitizing agent per manufacturer's instructions. Rinse the inside again with clear warm water several times to be certain that all traces of sanitizer have been removed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 53 of 70 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 11/08/2024 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 During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. f. During an observation on 11/6/2024 at 9:55 a.m. the mixer internal parts had dried up food buildup. During an interview on 10/8/2024 at 10:17 a.m. with ADS, ADS stated they last used the mixer yesterday at dinner time to mix the pudding. ADS stated it was the cooks and cook assistant's responsibility to clean the mixer after each use and a cleaner comes in once a week to detail clean. ADS stated the mixer internal parts had dried food buildup and it was not okay as it should have been cleaned yesterday after use. ADS state the potential outcome to residents would be vomiting and diarrhea as the mixer could have bacteria in it. During a review of facility's cleaning schedule titled, Daily Cleaning Schedule, dated 7/19/2024, the P&P indicated, there was not a schedule for cleaning the mixer. During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6). g. During a concurrent observation and interview on 11/6/2024 at 10:28 a.m. with DS in the pot storage area, there was a cellphone on top of the pot. DS stated it was a personal cellphone of [NAME] 1. During an interview on 11/6/2024 at 10:31 a.m. with DS, DS stated staff could not use or store their cellphone in the working area as it would be a distraction for them and there could be cross-contamination of food as phones could be dirty. DS stated residents could get sick of foodborne illnesses as a potential outcome. During a review of the facility's P&P titled, Phone/Personal Belongings of Employee Storage Area, dated 7/9/2024, the P&P indicated Handling your cellphone can pass along bacteria. The phone may have germs from your mouth or hands. (Recommend use of cellphone be limited to breaks unless an emergency, as well as personal belongings, and emphasis washing hands after touching or using cellphone and personal belongings). During a review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 54 of 70 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 11/08/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to enforce its policy and procedures of storing food brought in by family or visitors in a way that it was either separate or easily distinguishable from facility food when there was no designated refrigerator space. Residents Affected - Some This failure had the potential to result in a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 95 of 96 facility residents. Findings: During an interview on 11/7/2024 at 2:12 p.m. with the Dietary Supervisor (DS), the DS stated they allowed family to bring food for the residents; however, family were not allowed to bring food for more than a meal. The DS stated if family brought food for more than one (1) meal, they must throw everything away because there was no designated refrigerator for residents in the kitchen and in the nurses' station. The DS stated this was not a good practice because residents could feel angry and feel bad. The DS stated she could store the food in the kitchen's refrigerator; however, would not be a good sanitary practice as it could cause cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). During an interview on 11/7/2024 at 2:34 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated they do not have a refrigerator in the nurses' station so if there were foods from the outside needing refrigerator they must refer to the DS. LVN 1 stated they could not let food requiring refrigeration just hanging out as it could spoil. LVN 1 stated he would suggest having a designated refrigerator for residents outside food to make it favorable for residents. LVN 1 stated residents may or may not feel bad as a potential outcome. During an interview on 11/7/2024 at 3:15 a.m. with the Director of Nursing (DON), the DON stated they do not have storage for extra food requiring refrigerator beyond one meal for the food of the residents coming from an outside source. The DON stated they used to have a refrigerator in Station 2; however, the refrigerator was used and labeled for staff use only. The DON stated they did not have a refrigerator designated for resident's food from the outside. The DON stated residents would feel deprived as a potential outcome of not being able to keep or store their food coming from their family or friends. During a review of the facility's policies and procedures (P&P) titled Food from Outside Sources, dated 7/19/2024, the P&P stated Food brought in from outside the facility kitchen for resident's consumption will be monitored. This is done to measure the effectiveness of this intervention in residents with low food intake, to be sure the food is within the guidelines of the diet order, and to better assess nutrient intake. Nursing and/or Admissions will provide the family of new admits with the information sheet Bringing in food for our residents. Procedure: Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator or in the residents' personal refrigerator. In the food service department, the policy on the food storage will apply. Otherwise, if unopened, refrigerated, or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened a disposed of in 2 days after opening. Frozen items such as ice cream, will be disposed in 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 55 of 70 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 11/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain documentation of offering advance directive (a legal document indicating resident preference on end-of-life treatment decisions) information to the resident/resident representative and of reviewing the resident's advance directive annually for one of two sampled residents (Resident 86) per facility's policy and procedure (P&P). This failure had the potential to result in not knowing the resident's wishes regarding end-of-life care and life-sustaining treatments which may lead to unwanted or inappropriate medical interventions. Findings: During a review of Resident 86's admission Record, the admission Record indicated the facility admitted the resident on 10/26/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and paranoid schizophrenia (a type mental illness that is characterized by disturbances in thought with symptoms of intense feeling of distrust or suspicion towards others). During a review of Resident 86's History and Physical (H&P) dated 11/1/2023, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 86's Minimum Data Set (MDS -a resident assessment tool) dated 9/13/2024, the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident did not have an advance directive. During a concurrent interview and record review of Resident 86's Care Conference meeting dated 10/3/2024, on 11/6/2024 at 1:33 p.m., with the Director of Nursing (DON), the DON stated during the care conference the Social Services Director (SSD) discusses the advance directive. The DON stated advance directive is discussed and offered to residents/resident representative upon admission and during quarterly or annual care conferences. The DON stated there should be documentation during the 10/3/2024 that advance directive was discussed and offered to the resident/resident's (Resident 86) representative. The DON stated the purpose of the advance directive is to ensure the resident's wishes are being followed. The DON stated the best person to talk to would be the SSD. During a follow-up interview and record review of the facility's P&P titled, Advance Directive, on 11/6/2024 at 2:49 p.m., the DON stated per their policy and procedures, the resident's advance directive should be reviewed annually and should be documented on the resident's medical record. During an interview on 11/6/2024 at 2:51 p.m., with the SSD, the SSD stated when a resident is first admitted , they check if the resident has advance directive and follow-up with family. The SSD also stated they offer advance directive and follow-up annually and/or during quarterly care plan meetings. The SSD stated for Resident 86, she forgot to document the discussion of advance directive. The SSD stated the purpose of documentation is to assure that they discussed it in the meeting with the resident and completed any follow-up. The SSD stated when residents are not offered assistance on formulating an advance directive, they would not know what the resident's wishes are especially if they are self-responsible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 56 of 70 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 11/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility policy and procedure (P&P) titled, Advance Directive, last reviewed 7/19/2024, the P&P indicated if the resident if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The P&P indicated the resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. The P&P indicated the nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. The P&P indicated the Interdisicplinary Team will review annually with the resident his or her advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). Event ID: Facility ID: 055002 If continuation sheet Page 57 of 70 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 11/08/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/10/2010 and readmitted the resident on 10/1/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), abnormal weight loss, and other lack of coordination. Residents Affected - Some During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had short-term and long-term memory problems and severe daily decision-making impairment, and was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers. The MDS further indicated Resident 3 received oxygen therapy. During a review of Resident 3's H&P, dated 10/17/2024, the H&P indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Order Summary Report, dated 10/16/2024, the Order Summary Report indicated to administer oxygen at two to three liters (a unit of measure for volume) per minute via nasal cannula or mask to maintain an oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) greater than 92 percent (%) every shift for episodes of low oxygen saturation. During a review of Resident 3's Treatment Administration Record (TAR), dated 11/5/2024, the TAR indicated Resident 3 was administered oxygen at two to three liters per minute via nasal cannula or mask to maintain an oxygen saturation greater than 92%. During a concurrent observation and interview with CNA 6, on 11/5/2024, at 10:24 a.m., inside Resident 3's room, CNA 6 confirmed Resident 3's nasal cannula tubing was touching the floor while connected to Resident 3's nose. CNA 6 stated Resident 3's nasal cannula tubing should not be touching the floor because the floor is dirty and can cause cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) between the floor and the tubing. CNA 6 further stated if cross-contamination occurs, there is potential for Resident 3 to get an infection. During an interview with the DON, on 11/8/2024, at 1:52 p.m., the DON stated nasal cannula tubing should not be touching the floor to prevent infection. The DON further stated the floor is a potential area for infection and residents can potentially get sick when their nasal cannula is touching the floor while connected to the resident. During a review of the facility's (P&P) titled, Surveillance for Infections, last reviewed 7/19/2024, the P&P indicated the infection preventionist will conduct ongoing surveillance for healthcare associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 58 of 70 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 11/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1.Ensure the indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not touching the floor for one of five sampled residents (Resident 16) reviewed during the Infection Control task. 2. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) were implemented by Housekeeper 1 (HSK 1) and Certified Nursing Assistant 5 for one of five sampled residents (Resident 16) reviewed during the Infection Control task. 3. Ensure resident nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was not touching the floor while connected to the resident for one of two sampled residents (Resident 3) reviewed under the respiratory care area. These failures had the potential to spread infections and illnesses among residents and staff. Findings: 1.a.During a review of Resident 16's admission Record, dated 11/7/2024, the admission Record indicated the facility admitted Resident 16 on 4/10/2024 and readmitted the resident on 9/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention), and encounter for a urinary device. During a review of Resident 16's History and Physical (H&P), dated 9/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated the resident had recently been hospitalized for severe sepsis (a potentially life-threatening complication of an infection) and a complicated urinary tract infection. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 10/14/2024, the MDS indicated Resident 16 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility. During a review of Resident 16's Order Summary Report, dated 11/1/2024, the Order Summary Report indicated the following orders: -Indwelling catheter for diagnosis of obstructive and reflux uropathy (interruption of urinary outflow at any level in the urinary tract), dated 10/15/2024. -Indwelling catheter: monitor every shift for signs and symptoms of infection such as pain, redness and drainage at the site; urine output for cloudiness, bleeding and sedimentation, dated 9/30/2024. During a review of Resident 16's Care Plan regarding an indwelling catheter, initiated 4/11/2024, the Care Plan indicated a goal that the resident would show no signs or symptoms of infection. During an observation on 11/5/2024 at 9:44 a.m., inside Resident 16's room, Resident 16 lay in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 59 of 70 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 11/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observed the indwelling catheter drainage bag inside of a privacy bag (pouch designed to easily slip over and discreetly conceal urine in a drainage bag from public view), the drainage bag inside the privacy bag was touching the floor. During a concurrent observation and interview on 11/5/2024 at 9:48 a.m., Certified Nursing Assistant 6 (CNA 6) entered Resident 16's room and stated the catheter bag was touching the floor. CNA 6 stated the drainage bag inside of the privacy bag should not be touching the floor to prevent infection in the resident. CNA 6 stated the drainage bag should be placed in a clean basin to create a barrier between the bag and the dirty floor. During an observation on 11/7/2024 at 11:45 a.m., Resident 16 lay in bed with the bed in the lowest position, observed the indwelling catheter drainage bag inside of a privacy bag and touching the floor. During a concurrent observation and interview on 11/7/2024 at 11:51 a.m., CNA 5 entered Resident 16's room and stated the resident's indwelling catheter drainage bag in the privacy bag was on the floor. CNA 5 stated she had removed the basin that was under the drainage bag because it was dirty. CNA 5 stated she was going to get a clean basin and lowered the resident's bed because she didn't want him to fall, but the drainage bag was left on the floor. CNA 5 stated she should have brought the clean basin to the room prior to removing the dirty basin so the drainage bag was not left on the floor. During an interview on 11/7/2024 at 1:28 p.m., with the Infection Preventionist (IP), the IP stated indwelling catheter drainage bags should be placed in a privacy bag and should not be on the floor. The IP stated drainage bags inside of privacy bags should be off the floor because dirt and germs from the floor can get on the drainage bag then travel to the resident causing an infection like a UTI. During an interview on 11/8/2024 at 11:34 a.m., with the Director of Nursing (DON), the DON stated indwelling catheter drainage bags in a privacy bag should not be on the floor. The DON stated if a drainage bag is on the floor, bacteria may travel from the floor to the resident potentially causing an infection. During a review of the facility policy and procedures (P&P) titled, Catheter Care, Urinary, last reviewed 7/19/2024, the (P&P) indicated the purpose of this procedure is to prevent catheter associated urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor. During a review of the facility's (P&P) titled, Surveillance for Infections, last reviewed 7/19/2024, the policy and procedure indicated the infection preventionist will conduct ongoing surveillance for healthcare associated infections and other epidemiologically (relating to the study of how diseases and disorders are spread, controlled, and impact populations) significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 1.b. During a concurrent observation and interview on 11/5/2024 at 9:39 a.m., with HSK 1, observed an Enhanced Standard Precaution sign posted at the entrance to Resident 16's shared room. Observed HSK 1 mopped the floor, touched a chair, and touched a wheelchair in the shared resident room. Observed HSK 1 did not don (put on) a gown while cleaning the environment. HSK 1 stated she should be wearing a gown while cleaning the room of an EBP resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 60 of 70 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 11/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/5/2024 at 9:40 a.m., with the Quality Assurance Nurse (QA), the QA stated she observed HSK 1 cleaning Resident 16's shared room and HSK 1 was not wearing a gown. The QA stated HSK 1 should have donned a gown while cleaning the environment to prevent the spread of infection. During a concurrent observation and interview on 11/7/2024 at 11:51 a.m., with CNA 5, observed an Enhanced Standard Precaution sign posted at the entrance to Resident 16's share room. Observed CNA 5 entered Resident 16's room and stated the resident's indwelling catheter drainage bag was on the floor. CNA 5 exited the room and then returned with a clean privacy bag and a clean basin. CNA 5 donned gloves, pulled the resident's covers up to access the drainage bag, removed the drainage bag from the dirty privacy bag, placed the clean privacy bag on the indwelling catheter drainage bag, then placed the drainage bag in the clean basin on the floor. Observed CNA 5 did not don a gown while accessing the indwelling catheter. During a follow interview on 11/7/2024 at 12:04 p.m., with CNA 5, CNA 5 stated Resident 16 was on EBP. CNA 5 stated EBP means staff must use a gown when changing the resident and changing his linens for infection control and to protect the resident. Observed CNA 5 refer to the EBP sign posted at Resident 16's room entrance. CNA 5 stated the EBP sign indicated to don a gown when providing care for an indwelling device. CNA 5 stated she did not wear a gown when she accessed Resident 16's indwelling catheter drainage bag. CNA 5 stated she did not don a gown because she was nervous, but she should have. During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed the facility provided Enhanced Standard Precaution Sign and policy and procedure regarding EBPs. The IP stated the facility (P&P) indicates to don a gown for high contact resident care activities. The IP stated the Enhanced Standard Precautions sign is used for residents on EBPs. The IP stated the sign indicates that all staff must don gloves and a gown when cleaning the environment or accessing an indwelling device. The IP stated gowns are worn to minimize the spread of MDROs from staff members clothing to susceptible residents with indwelling devices like an indwelling catheter. The IP stated CNAs should don a gown and gloves when touching the indwelling catheter drainage bag because the catheter tubing could transmit bacteria to the resident causing an infection. The IP Stated housekeepers should also don a gown and gloves when cleaning the room of a resident on EBPs because there are other residents in the shared room and the gown and gloves prevents the transmission of bacteria from one resident to another resident potentially causing infection. During a interview on 11/8/2024 at 11:34 a.m., with the DON, the DON stated EBP is a technique to protect residents prone to infection, including residents with indwelling catheters, from cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of MDROs. The DON stated HSK 1 and CNA 5 did not follow the facility policy when they did not don gowns while providing care and while cleaning the environment for a resident on EBP. During a review of the facility-provided Los Angeles County Department of Public Health Enhanced Standard Precautions sign, dated 9/8/2021, the sign indicated to wear gloves and a gown for high contact resident care activities including activities of daily living, caring for devices, and cleaning the environment. During a review of the facility (P&P) titled, Enhanced Barrier Precautions, last reviewed 7/19/2024, the (P&P) indicated EBPs are an infection prevention and control intervention and are utilized to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 61 of 70 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 11/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete prevent the spread of MDROs to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity and PPE is changed before caring for another resident. Examples of high contact resident care activities requiring providing hygiene, assisting with toileting, device care or use (urinary catheter). EBPs are indicated for residents with wounds or indwelling medical devices regardless of MDRO colonization. Event ID: Facility ID: 055002 If continuation sheet Page 62 of 70 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 11/08/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of the pneumococcal vaccine (medication used to prevent pneumonia [serious lung infections caused by streptococcus pneumoniae, a type of bacteria]) and the 2024/2025 influenza vaccine (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for one of five sampled residents (Resident 16) reviewed during the Infection Control task. Residents Affected - Few This deficient practice had the potential to result in adverse reactions (any unexpected or dangerous reaction) from the vaccines and the denial of the resident's right to refuse vaccines. Findings: During a review of Resident 16's admission Record, dated 11/7/2024, the admission Record indicated the facility admitted Resident 16 on 4/10/2024 and readmitted the resident on 9/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), and benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention). During a review of Resident 16's History and Physical (H&P), dated 9/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 10/14/2024, the MDS indicated Resident 16 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility. During a review of Resident 16's Physician Orders, the Physician Orders indicated the following: - Pneumococcal 20 - Valent Conjugate vaccine (pneumonia vaccine), inject 0.5 milliliters (mL, a unit of measurement) intramuscularly (by way of the muscle) one time only for pneumonia immunization (the process of making a person resistant to disease), monitor site for redness, pain, swelling, bleeding, or any adverse condition for three days, report to the physician when noted, dated 10/17/2024. - Influenza Virus vaccine, inject 0.5 mL intramuscularly one time only for seasonal flu vaccination, dated 10/16/2024. During a review of Resident 16's Nursing Clinical Notes, the clinical notes indicated the following: -On 10/16/2024 at 2:27 p.m., the Infection Preventionist (IP) noted that signed consent for the annual influenza vaccine was obtained, and the vaccine was administered on the left deltoid. - On 10/18/2024 at 2:29 p.m., the IP noted signed consent for the pneumococcal vaccine was obtained, and the vaccine was administered on the Left Deltoid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 63 of 70 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 11/08/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 16's Informed Consent for Pneumococcal Vaccine form, undated, the form indicated it was not signed by the resident or resident representative, was not marked to indicate that consent was obtained for receiving the vaccine and was not marked to indicate information was received about the risk and benefits of the vaccine. During a review of Resident 16's Informed Consent for Influenza Vaccine form, undated, the form indicated it was not signed by the resident or resident representative, was not marked to indicate that consent was obtained for receiving the vaccine and was not marked to indicate information was received about the risk and benefits of the vaccine. During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 16's physician orders for 10/2024; Informed Consent for Influenza Vaccine form, undated; Informed Consent for Pneumococcal Vaccine form, undated; Nursing Clinical Notes for 10/2024; and Medication Administration Record. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines. The IP stated if a resident will receive a vaccine, then informed consent is obtained from the resident or resident representative and education is provided regarding the risk and benefits of the vaccine. The IP stated the benefit of vaccines is that they prevent illness. The IP stated the risk of vaccines are there are potential side effects from vaccine administration. The IP stated the influenza vaccine was administered to Resident 16 on 10/16/2024 and the pneumonia vaccine was administered on 10/18/2024. The IP stated he overlooked obtaining informed consent for Resident 16's vaccines and he thought the facility had received the signed consent form during the resident's admission and prior to vaccine administration from the resident's public guardian (a person appointed to be responsible for the care of individuals who are no longer able to make decisions or care for themselves), but they had not received informed consent. The IP stated the importance of obtaining informed consent prior to vaccine administration is that the public guardian makes decisions in the best interest of the resident and is appointed by the court to give consent for medical treatments. The IP stated when vaccines are administered without obtaining informed consent, residents may receive medical treatment they do not want. The IP stated he assumed he had received informed consent for the administration of vaccines to Resident 16, but he never talked with the resident's public guardian. During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated she was made aware that the IP administered vaccines to Resident 16 without obtaining informed consent. The DON stated the facility process is the admission nurse discusses vaccines with the resident or resident representative and obtains consent. The DON stated prior to the administration of the vaccine, consent should be verified by the IP. The DON stated the resident or resident representative have the right to refuse any treatment including vaccines. The DON stated resident rights must be respected. The DON stated when Resident 16's public guardian did not provide consent it could potentially result in harm to the resident from adverse effects of the vaccine or the resident receiving a vaccine they do not want. The DON stated the facility policy regarding vaccine administration was not followed. During a review of the facility policy and procedures (P&P) titled, Infection Preventionist, last reviewed 7/19/2024, the (P&P) indicated the IP is responsible for coordinating the implementation and updating the infection prevention and control program (IPC). The IP has obtained specialized IPC training beyond initial professional training or education prior to assuming the role, including the prevention of respiratory infections (pneumonia, influenza). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 64 of 70 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 11/08/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility policy and procedures (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the (P&P) indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be informed and provided information and education regarding the benefits and potential side effects of the vaccinations. Provisions of such education shall be documented in the resident's medical record. The resident or resident's legal representative may refuse vaccines for any reason. During a review of the facility (P&P) titled, Influenza Vaccine, last reviewed 7/19/2024, the policy indicated all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or residents' legal representatives). Between October 1st and March 31st each year the vaccine will be offered. Prior to the vaccination, the resident (RP) will be provided information and education regarding the benefits and potential side effects of the vaccine. Provision of such education is documented in the resident's medical record. The resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. During a review of the facility (P&P) titled, Pneumococcal Vaccine, last reviewed 7/19/2024, the policy indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the vaccine and when indicated, are offered the vaccine within 30 days of admission unless medically contraindicated or the resident has already received the vaccine. Prior to receiving the vaccination, the resident (or RP) will be provided information and education regarding the benefits and potential side effects of the vaccine. Provision of such education is documented in the resident's medical record. The resident or resident's legal representative have the right to refuse vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 65 of 70 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 11/08/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide education about the risks and benefits of, obtain consent or refusal for, and/or administer the 2023/2024 coronavirus disease 2019 vaccine (medication used to prevent complications from COVID-19 [a highly contagious viral infection that can trigger respiratory tract infection]) for three of five sampled residents (Resident 16, 57, and 91) reviewed during the Infection Control task by failing to: 1. Ensure informed consent was obtained prior to the administration of the 2024/2025 COVID-19 vaccine to Resident 16. 2. Offer and/or clarify with the physician the appropriateness for the administration of the 2024/2025 COVID-19 vaccine for Resident 57. 3. Ensure vaccine education was provided and documented per the facility policy and procedures prior to the administration of the 2024/2025 COVID-19 for Resident 91. These deficient practices had the potential to result in adverse reactions (any unexpected or dangerous reaction to a drug) to receiving vaccines, denial of the resident's right to refuse vaccines, and an increased risk of residents developing complications from COVID-19 including acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen). Findings: 1.During a review of Resident 16's admission Record dated 11/7/2024, the admission Record indicated the facility admitted Resident 16 on 4/10/2024 and readmitted the resident on 9/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), and benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention). During a review of Resident 16's History and Physical (H&P) dated 9/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) dated 10/14/2024, the MDS indicated Resident 16 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility. During a review of Resident 16's Physician Orders, the Physician Orders indicated: - COVID - 19 vaccine inject 0.3 milliliters (mL, a unit of measurement) intramuscularly (by way of the muscle) one time only for COVID - 19 bivalent booster vaccine (a seasonal COVID-19 vaccine), observe resident and administration site for fifteen minutes after vaccine administration, dated 10/4/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 66 of 70 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 11/08/2024 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 0887 During a review of Resident 16's Nursing Clinical Notes, the clinical notes indicated the following: Level of Harm - Minimal harm or potential for actual harm - On 10/7/2024 at 3:56 p.m., the Infection Preventionist (IP) noted that signed consent for the COVID-19 vaccine was obtained, and the vaccine was administered on the left deltoid (muscle in the arm). Residents Affected - Some During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 16's physician orders for 10/2024, Nursing Clinical Notes for 10/2024, and Medication Administration Record. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines. The IP stated if a resident will receive a vaccine, then informed consent is obtained from the resident or resident representative and education is provided regarding the risk and benefits of the vaccine. The IP stated the benefit of vaccines is that they prevent illness. The IP stated the risk of vaccines are there are potential side effects from vaccine administration. The IP stated the COVID-19 vaccine was administered to Resident 16 on 10/7/2024. The IP stated he overlooked obtaining informed consent for Resident 16's COVID-19 vaccine. The IP stated he thought the facility had received the signed consent form during the resident's admission process and prior to vaccine administration from the resident's public guardian (a person appointed to be responsible for the care of individuals who are no longer able to make decisions or care for themselves), but they had not received consent. The IP stated the importance of obtaining informed consent prior to vaccine administration is the public guardian makes decisions in the best interest of the resident and is appointed by the court to give consent for medical treatments. The IP stated when vaccines are administered without obtaining informed consent, residents may receive medical treatment they do not want. The IP stated he assumed he had received informed consent for the administration of vaccines to Resident 16, but he never talked with the resident's public guardian. During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated she was made aware that the IP administered vaccines to Resident 16 without obtaining informed consent. The DON stated the facility process is the admission nurse discusses vaccines with the resident or resident representative and obtains consent. The DON stated prior to the administration of the vaccine, consent should be verified. The DON stated the resident or resident representative have the right to refuse any treatment including vaccines. The DON stated resident rights must be respected. The DON stated when Resident 16's public guardian did not provide consent it could potentially result in harm to the resident from vaccine adverse effects or the resident receiving a vaccine they do not want. The DON stated the facility policy regarding vaccine administration was not followed. During a review of the facility policy and procedures (P&P) titled, Infection Preventionist, last reviewed 7/19/2024, the (P&P) indicated the IP is responsible for coordinating the implementation and updating the infection prevention and control program (IPC). The IP has obtained specialized IPC training beyond initial professional training or education prior to assuming the role, including the prevention of respiratory infections. During a review of the facility (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the policy indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be informed and provided information and education regarding the benefits and potential side effects of the vaccinations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 67 of 70 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 11/08/2024 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 0887 Provisions of such education shall be documented in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm During a review of the facility (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed 7/19/2024, the policy indicated each resident is offered the COVID - 19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The resident or RP has the opportunity to accept or refuse a COVID-19 vaccine. COVID - 19 vaccine education and documentation are overseen by the IP and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Residents must sign a consent to vaccinate form prior to receiving the vaccine. Select adverse events for COVID-19 vaccines are reported, including serious adverse events, multisystem inflammatory syndrome (a group of symptoms linked to swollen, inflamed, organs or tissues) in adults, and cases of adverse events that result in hospitalization or death. Residents Affected - Some 2. During a review of Resident 57's admission Record dated 10/28/2024, the admission Record indicated the facility admitted Resident 57 on 12/6/2022 and readmitted the resident on 10/25/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain ), and dementia (a progressive state of decline in mental abilities). During a review of Resident 57's H&P, dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. The H&P further indicated the resident was re-admitted from the hospital and was in stable condition. During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 57 had the ability to understand others and the ability to be understood. The MDS further indicated the resident required partial/moderate assistance with dressing and personal hygiene, and required substantial/maximal assistance with toileting and bathing. During a review of Resident 57's Physician Orders, the Physician Orders indicated: - May have COVID - 19 vaccine, dated 10/25/2024. During a review of Resident 57's Immunization Audit Report, dated 11/7/2024, the audit report indicated the COVID-19 vaccine was last administered on 12/16/2023. During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 57's physician orders for 10/2024 and Immunization Audit Report. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines including the COVID-19 vaccine. The IP stated the COVID-19 vaccine was last administered to Resident 57 on 12/16/2024 and the resident had not received the 2024/2025 COVID-19 vaccine. The IP stated the resident was recently hospitalized and the IP decided the resident should not receive the COVID-19 vaccine. The IP stated he did not contact the resident's physician regarding the COVID-19 vaccine. The IP stated the resident's physician should have been notified to make the decision regarding the appropriateness for the administration of the COVID - 19 vaccine, but the physician was not contacted. The IP stated the resident's physician knows the resident's medical condition and the physician should be the one to decide to give an order to give or not give the COVID-19 vaccine. The IP stated when he decided to not give Resident 57 the COVID-19 vaccine and did not consult with the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 68 of 70 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 11/08/2024 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 0887 physician it could potentially result in the resident becoming ill from pneumonia caused by COVID-19. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the DON, the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated Resident 57's physician and family should make the decision whether to give the COVID-19 vaccine. The DON stated it is a medical decision to not give a vaccine and medical decisions are made by physicians. The DON stated it was not within the IP's scope of practice to decide that COVID-19 vaccine was not appropriate for Resident 57. The DON stated vaccines are administered for the prevention of illness or to lesson the effects of the illness. The DON stated when a vaccine is not administered it may result in resident's being more prone to illness. Residents Affected - Some During a review of the facility (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the policy indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Certain vaccines may be administered per the physician approved facility protocol after the resident has been assessed by the physician for medical contraindications for each vaccine. During a review of the facility (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed 7/19/2024, the policy indicated each resident is offered the COVID - 19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. Residents who are eligible to receive the vaccine are strongly encouraged to do so. Residents are screened for contraindications to the vaccine, medical precautions and prior vaccination before being offered the vaccine. 3. During a review of Resident 91's admission Record dated 7/17/2024, the admission Record indicated the facility admitted Resident 91 on 2/29/2024 and readmitted the resident on 7/16/2024 with diagnoses that included severe sepsis (a life-threatening blood infection), urinary tract infection (an infection in the bladder/urinary tract), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the sacral region (region at the bottom of the spine), and infection of the skin and subcutaneous (below the skin) tissue. During a review of Resident 91's H&P, dated 7/16/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 91's MDS, dated [DATE], the MDS indicated Resident 91 had the ability to understand others and usually had the ability to be understood. The MDS further indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility. During a review of Resident 91's Nursing Clinical Notes for 10/2024, the clinical notes indicated on 10/7/2024 at 3:21 p.m., the IP noted that verbal consent for the COVID vaccine was obtained, and the vaccine was administered on the left deltoid. The Nursing Clinical Notes did not indicate that education regarding the risk and benefits of the vaccine were provided. During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 91's physician orders for 10/2024, Nursing Clinical Notes for 10/2024, and Medication Administration Record. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines. The IP stated if a resident will receive a vaccine, then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 69 of 70 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 11/08/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some informed consent is obtained from the resident or resident representative and education is provided regarding the risk and benefits of the vaccine. The IP stated the benefit of vaccines is that they prevent illness. The IP stated the risk of vaccines are there are potential side effects from vaccine administration. The IP stated the COVID-19 vaccine was administered to Resident 91 on 10/7/2024. The IP stated he could not find an Informed Consent form for the COVID-19 vaccine for Resident 91. The IP stated he received verbal consent and documented it in the Clinical Notes. The IP stated there was no documented evidence that education regarding the risk and benefits of the COVID-19 vaccine was discussed with the resident's representative. The IP stated the importance of providing education regarding vaccines is so the family is aware the benefits and the risks of vaccination. During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the DON, the DON reviewed the facility policy and procedures regarding vaccine administration and Resident 91's Nursing Clinical Notes dated 10/7/2024. The DON stated the IP did not document that education regarding the risk and benefits of the COVID-19 vaccine were discussed prior to the administration of the vaccine. The DON stated the importance of documenting that education was provided was to ensure the family was aware of reason for receiving the vaccine and the possible side effects because the family has the right to refuse the vaccine after hearing the potential side effects. During a review of the facility (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the policy indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be informed and provided information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education shall be documented in the resident's medical record. During a review of the facility (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed 7/19/2024, the policy indicated each resident is offered the COVID - 19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. COVID - 19 vaccine education and documentation are overseen by the IP and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 70 of 70