Inspection·November 27, 2024

F 0712 5. 10/4/2024- seen by NP. Level of Harm - Minimal harm or potential for actual harm The DON stated it has been six months since AP last visited Resident 1. The DON stated the NP comes and visit Resident 1 monthly. The DON stated the importance of timely AP visit was to assure Resident 1's health and develop trust with the resident. Residents Affected - Few During a concurrent interview and record review on 11/27/2024, at 3:29 p.m., with the DON, facility's policy and procedure (PP) titled, Physician Visits, dated 4/2008 and last reviewed on 10/25/2024, the PP indicated, The Attending Physician must visit his or her residents at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter. 2. After the first 90 days, if the Attending Physician determines that a resident need not be seen by him or her every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or nurse practitioner may make alternate visits after the initial 90 days following admission, unless restricted by law or regulation. The DON stated the PP was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on interview and record review, the facility failed to ensure therapeutic diets (a customized meal plan designed by a healthcare professional to treat a specific medical condition) were served as prescribed by the physician for one of three sampled residents (Resident 2). This deficient practice can prevent Resident 2 from receiving the benefit of the therapeutic diet. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2024, with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN-high blood pressure). During a record review of Resident 2's History and Physical (H&P), dated 3/5/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a record review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 9/4/2024, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required supervision with eating. The MDS indicated Resident 2 was on therapeutic diet. During a record review of Resident 2's Physician Order, dated 9/12/2024, the Physician Order indicated controlled carbohydrate diet (carefully monitoring and keeping the amount of carbohydrates you eat each day relatively the same, usually to help manage blood sugar levels, by eating similar portions of carbohydrate rich foods at every meal), regular texture, thin regular liquid consistency, non-fat milk, eight ounces with meals and large portion with all meals. During a record review of Resident 2's Care Plan related to DM, dated 3/4/2024, the Care Plan indicated an intervention to provide diet as ordered. During an interview on 11/25/2024, at 9:44 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) does not inform the charge nurses assigned when Resident 2 requested for a second plate of food because Resident 2 was alert and had a good appetite. CNA 1 stated she (CNA 1) did not know if Resident 2 was diabetic. CNA 1 stated she (CNA 1) should have checked and asked the charge nurse before requesting food in the kitchen. During an interview on 11/25/2024, at 10:22 a.m., with the Dietary Supervisor (DS), the DS stated Resident 2 will have elevated blood sugar if given extra portion or second plate of food. During an interview on 11/25/2024, at 10:38 a.m., with Registered Nurse 1 (RN 1), RN 1 stated CNA 1 should notify charge nurses if Resident 2 request extra portion or second plate of food. RN 1 stated Resident 2 had diabetes and if given an extra portion or second plate of food, Resident 2's blood sugar will increase. During an interview on 11/25/2024, at 11:29 a.m., with the Director of Nursing (DON), the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055002 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated residents who request extra portion, or second plate of food need to inform the CNAs, then the CNAs would then inform the charge nurse. The DON stated charge nurses would then fill up the Diet Order and Diet Changes form and show it to the kitchen staff. The DON stated Resident 2's blood sugar would be uncontrolled due to extra portion of food. During a concurrent interview and record review on 11/27/2024, at3:14 p.m., with the DON, the facility's policy and procedure titled, Diet Orders, dated 2023 and last reviewed on 10/25/2024, the PP indicated, Diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services (FNS) Department. Nursing will send a Diet Order Communication slip to the Food and Nutrition Services Department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. The diet count is also to be adjusted as needed. The diet profile and tray card will be removed upon discharge or transfer. Any discrepancy in the diet order slip will be clarified by the FNS Director or [NAME] in charge with Nursing. The DON stated it is their policy to follow physician's order. Event ID: Facility ID: 055002 If continuation sheet Page 4 of 4