Health inspection·May 26, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/25/2023, at 9:58 am, Licensed Vocational Nurse 2 (LVN 2) stated privacy was important to protect resident's dignity and self-respect. b. During a review of Resident 284's admission Record indicated, Resident 284 was admitted to the facility on [DATE] with diagnoses that included left pubis fracture (break in pelvis bone), left acetabulum fracture (break in hip bone), and repeated falls. During a review of Resident 284's Skilled Nursing Facility History and Physical, dated 5/23/2023, indicated Resident 284 was alert and oriented to person, place, and time and Resident 284's mental status was at baseline. During a review of Resident 284's care plan, initiated 5/23/2023, indicated Resident 284 had self-care deficits and was at risk for unavoidable decline for bed mobility, dressing, and toileting. Interventions included to assisted Resident 284 with toileting or incontinent (lack of voluntary control over urination or defecation [discharge of feces from the body]) care as needed and no strenuous exercise. During an observation and interview on 5/24/2023, at 3:25 pm, CNA 1 was removing Resident 284's pants on Resident 284's bed. The door to the room was shut and the privacy curtains alongside the sliding glass door, which lead to a patio, was left open. CNA 1 stated staff, visitors, and residents could walk on the patio. CNA 1 stated she removed Resident 284's pants so Resident 284 could be more comfortable while in bed. CNA 1 stated the privacy curtain needed to be closed all the way when changing Resident 284 to give Resident 284 privacy, or people could see Resident 284's private areas. During an interview on 5/24/2023, at 3:45 pm, Licensed Vocational Nurse 1 (LVN 1) stated the privacy curtain by the window/sliding glass door and restroom must be shut when staff were changing the residents (in general) or performed any patient care tasks. LVN 1 stated [if privacy curtains were not closed] someone could see the resident's private areas, and this could make the residents feel embarrassed. During an observation on 05/26/23, at 12:02 pm, CNA 5 was in the restroom located in Resident 284's room. Resident 284's room door and privacy curtain were open, and Resident 284 was being helped on to the toilet. CNA 5 exited the room leaving the room door and privacy curtain open and stated she would be back. During an observation on 05/26/23, at 12:06 pm, CNA 5 came back into Resident 284's room and into the restroom and CNA 5 did not close the room door or restroom curtain before assisting Resident 284 up from the toilet. During an interview on 5/26/2023, at 12:10 pm, CNA 5 stated she assisted Resident 284 to the toilet. CNA 5 stated the room door or bathroom privacy curtain was to be closed when Resident 284 was in the restroom. CNA 5 stated she did not ensure either were closed because Resident 284's responsible party (RP) was in the room. CNA 5 stated it was important to provide privacy while Resident 284 was using the restroom because Resident 284 was exposed, and someone could see her in a vulnerable position and make Resident 284 feel uncomfortable. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 2 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 indicated staff will promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 3 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 21), who was a writer, was provided with adequate furnishing to accommodate the use of a personal computer when Resident 21's desk broke. Residents Affected - Few This failure resulted in Resident 21 not being able to use his personal computer to continue writing a book and had the potential to result in a decline of Resident 21's psychosocial well-being. Findings: During a concurrent observation and interview on 5/23/2023, at 11:20 am., Resident 21 was in his room and a desktop computer monitor was on the floor with a keyboard on top of a stool located next to a desk. Resident 21 stated, the computer had been on top of a desk but Resident 21 backed up on the desk pretty hard, am hoping maintenance will take care of it. Resident 21 stated he was supposed to see the Social Worker (SW). During a concurrent observation and interview on 5/24/2023, at 8:31 am., Resident 21 was in his room, the desktop computer monitor was on the floor with the keyboard on top of a stool. Resident 21 stated, backing his wheelchair onto the desk where the computer was place, and the equipment came tumbling down. The facility took the desk, to put it back together about a month ago. Resident 21 stated, not being able to use his computer, certainly restricts me, am trying to finish a book, on technology. Resident 21 stated, the facility had offered for Resident 21 to use the bedside table but it's very awkward, it's better to put it in one place, the desk. During a review of Resident 21's admission Record (AR), indicated, Resident 21 was originally admitted to the facility on [DATE] and last admitted on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), insomnia (a common disorder of persistent problems falling and staying asleep) and paraplegia (paralysis that occurs in the lower half of the body). During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/11/2022, indicated, Resident 21 was cognitively intact (ability to think and reason) for daily decision making. During a review of Resident 21's History and Physical Examination (H&P), dated 9/9/2022, the H&P indicated, Resident 21 had the capacity to make decisions. During a review of Resident 21's Progress Notes (PN), dated 5/7/2023, timed at 1:40 pm., the PN indicated, Resident 21's wife came to the nursing station to inform Licensed Vocation Nurse 4 (LVN 4), Resident 21 ran into his desk with his power chair (electric wheelchair). The PN indicated, Resident 21 would like the desk left as is until maintenance could look at it. The PN indicated, message was left for maintenance to follow up. During an interview on 5/25/23, at 10:00 am., with the SW, the SW stated, Resident 21 backed up into his desk with his power chair last week. The SW stated, Resident 21 's desk was made of fiberglass and maintenance said the desk was not salvageable. The SW stated, Resident 21 was offered a larger room and Resident 21's wife was getting a desk and enlisted the facility's interior designer to help (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 4 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the new room. The SW stated, Resident 21 and wife have an appointment next week with IT (Information Technology, a professional of data or computer system). During an interview on 5/25/23, at 12:29pm., with the Maintenance Supervisor (MS), the MS stated, maintenance was not aware about Resident 21's broken desk. The MS stated, the facility did not usually fix resident's personal belongings and instead notified family. The MS stated, the SW would usually follow up on these matters. During an interview on 5/25/23, at 1:43 pm., with the General Maintenance (GM), the GM stated, maintenance was not aware about Resident 21's broken desk. The GM stated, when he checked in with the SW today, the SW stated EVS (Environmental Services, non-clinical healthcare staff like housekeeping) threw it away, so I never saw it. During a concurrent interview and record review on 5/25/23, at 2:45 pm., with the SW, Resident 21's PN, dated 5/16/23, timed at 11:00 am. and 5/17/23, timed at 1:58 p.m., were reviewed. The PN did not indicate, any documentation regarding Resident 1's broken desk or any accommodations provided by the facility. The SW stated, if it was not documented, it was not done. The SW stated, it was important to document to ensure the facility honored resident preferences. During an interview on 5/25/23, at 2:55 pm., with Licensed Vocation Nurse 1 (LVN 1), LVN 1 stated, staff reported to family, the SW, and contacted maintenance either by email or phone call in the event a resident's personal property got damaged. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated, The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other resident's would be endangered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 5 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for one of one sampled resident (Resident 6), the correct low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress setting was used per Resident 6's weight. Residents Affected - Few This failure had the potential to result in the development of pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]) to Resident 6. Findings: During a review of Resident 6's admission Record indicated she was admitted on [DATE] with diagnoses that included contractures (shortening and hardening of muscles, tendons, and other tissue) on the right and left elbow, contractures of the left and right hand, Parkinson's Disease (affects movement and often includes tremors), and pemphigoid (rare skin condition causing large, fluid-filled blisters). During a review of Resident 6's History and Physical (H&P), dated 2/19,2023, the H&P indicated, Resident 6 was non-verbal and did not have the capacity to make medical decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 4/6/2023, indicated Resident 6 had severe cognitive impairment (processes of thinking and reasoning), and Resident 6 was totally dependent for bed mobility and activities of daily living (ADL). During a review of Resident 6's care plan, revised on 4/14/2023, indicated Resident 6 was at risk for developing pressure ulcers and due to impaired mobility and severe cognitive impairment. The interventions included checking the function of Citadel Patient Therapy System Bed (LAL) every shift. During a concurrent observation and interview on 5/24/2023, at 11:45 am. Resident 6's LAL mattress was set at 250 pounds (lbs.). Licensed Vocational Nurse 3 (LVN 3) stated the LAL mattress setting was based on the resident's weight and the setting on the bed was programed by the nurses. LVN 3 stated the appropriate setting for Resident 6's LAL mattress was 165 lbs. LVN 3 stated sometimes the buttons on the LAL mattress accidentally get pushed. LVN 3 stated the correct LAL setting was important because it helped prevent breakdown of the skin and if the setting was correct, it would not prevent skin breakdown. During a concurrent interview and record review of the manufacturer guidelines on 5/25/2023, at 2:48 pm., the Director of Nursing (DON) stated LAL mattress settings depended on manufacturer guidelines and the facility programmed according to the weight of the residents. The DON stated it was important for a resident's LAL mattress setting to be programmed based on the weight because the purpose of the mattress was to protect the skin and prevent pressure ulcers. The DON stated Resident 6's LAL mattress setting was incorrect and set at 250 lbs. and should have been set at 165 lbs. During a review of the Citadel Patient Therapy System, Instructions for Use (manufacturer's guidelines), dated 12/2015, indicated to press the height/weight preset button to select the preset that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 6 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 most closely corresponds to the patient's body type and weight. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy & procedure (P&P) titled, Support Surface Policy, dated 4/2023, the P&P indicated, During rounds licensed nurse will observe low air loss (LAL) mattress setting is correct. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 7 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of six sampled residents (Resident 21 and 20) with limited range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility. a. For Resident 21, who was left-hand dominant with left sided weakness, the facility failed to complete Rehabilitation Screening Forms in accordance with the facility's policy and provide and provide an adequate exercise program to maintain Resident 21's ROM in both arms as indicated by the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) discharge recommendations, dated 1/22/2022. b. For Resident 20, the facility did not have any documented evidence Resident 20 performed sit to stand transfers three times per week to maintain mobility. These failures had the potential to result in Resident 21 and Resident 20 to experience a decline in ROM and mobility. Findings: a. During a review of Resident 21's admission Record indicated the facility originally admitted Resident 21 on 5/19/2021 and was re-admitted on [DATE]. The admission Record indicated Resident 21's diagnoses included Parkinson's disease (progressive disease of the nervous system resulting impaired movement), fusion (surgical connection) of the cervical region (neck) of the spine, and left shoulder osteoarthritis (bone disease that progresses over time, resulting in joint pain and stiffness). During a review of Resident 21's physician orders, dated 11/22/2022, indicated RNA for left arm AROM every day five times per week as tolerated. An additional physician's order for Resident 21, dated 11/22/2022, indicated RNA for right arm AROM every day five times per week as tolerated. During a review of Resident 21's OT Daily Encounter Notes (OT treatment notes) for 1/2022 indicated Resident 21 performed arm active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises on 1/7/2022, 1/11/2022, 1/13/2022, 1/14/2022, and 1/18/2022. During a review of Resident 21's OT Discharge summary, dated [DATE], indicated recommendations for a Restorative Nursing Program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) for AAROM exercises. During a review of Resident 21's care plan for ROM, initiated on 1/26/2022, indicated to provide RNA treatments as ordered for right arm active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) and left arm AROM every day five times per week as tolerated. During a review of Resident 21's clinical record, the record did not include any Rehabilitation Screening Forms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 8 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 21's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 5/11/2023, indicated Resident 21 had clear speech, clearly expressed ideas and wants, understood verbal content, and was cognitively intact (clear ability to think, understand, learn, and remember). The MDS indicated Resident 21 required supervision (oversight, encouragement, or cueing) for eating and personal hygiene and extensive assistance (resident involved in activity while staff provide weight-bearing support) for bed mobility, transfers between services, dressing, and toilet use. The MDS indicated Resident 21 had functional ROM limitations in both arms and both legs. During a concurrent observation and interview on 5/24/2023, at 9:19 am, in Resident 21's room, with Restorative Nursing Aide 1 (RNA 1), Resident 21 sat in a cushioned armchair while performing arm and legs exercises. Resident 21 repeatedly lifted the right arm in front of the body (shoulder flexion) to approximately shoulder height (90 degrees of motion). Resident 21 repeatedly lifted the right arm away from the body (shoulder abduction) to less than shoulder height. Resident 21's left shoulder flexion was limited to approximately half-way to shoulder height and stated, this is as much as I can do. Resident 21 then performed left shoulder abduction exercises but stopped at four repetitions due to Resident 21's difficulty lifting the arm away from the body. RNA 1 stated Resident 21's left side was weaker than the right side. During an interview on 5/24/2023, at 9:41 am, RNA 1 stated Resident 21 performed AROM exercises to both arms. During an interview on 5/25/2023, at 8:55 am, in Resident 21's room, Resident 21 stated Resident 21's left side became weaker two years ago due to neck stenosis (spaces in the spine narrow and create pressure on the spinal cord). Resident 21 stated Resident 21 underwent neck surgery to prevent Resident 21 from having quadriplegia (weakness or paralysis in both arms and both legs) but the left sided weakness did not improve. Resident 21 stated the weakness to the left side was problematic since Resident 21 was left-hand dominant. During a concurrent interview and record review on 5/25/2023, at 1:04 pm, with the Director of Rehabilitation (DOR), the DOR reviewed Resident 21's OT Discharge summary, dated [DATE]. The DOR stated the OT recommendations for Resident 21 included RNA for AAROM exercises. The DOR stated Resident 21 would benefit from AAROM program if Resident 21 had limited AROM. The DOR stated Resident 21 could potentially develop joint stiffness or impaired mobility if Resident 21 was not assisted to perform the full available ROM in each joint. The DOR stated Resident 21's limited ROM in the arms, including the weakness in the left dominant arm, was not reported. The DOR stated Resident 21 would benefit from an OT evaluation. During an interview on 5/26/2023, at 9:56 am, the DOR stated the Rehabilitation Screening Forms (in general) were not located in the facility's electronic documentation system. During a concurrent interview and record review on 5/26/23, at 10:16 am, with the Director of Nursing (DON) and the Director of Medical Records (DMR), the DON and DMR reviewed Resident 21's clinical record. The DON and DMR did not locate any Rehabilitation Screening Forms in the electronic documentation system or in Resident 21's physical (paper) clinical records. The DON stated the Rehabilitation Screening Forms were not completed for Resident 21 and there was no documentation in the clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 9 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy titled, Rehabilitation Screening, approved on 7/13/2018, indicated the Rehabilitation screen provided a benchmark (reference point) of patients' status for future comparison and will facilitate care planning to meet the patient's individual needs. The policy further indicated a Rehabilitation Screening Form will be completed for all residents upon admission, readmission, annually, after a fall, change of condition, and as necessary. Residents Affected - Some b. During a review of Resident 20's admission Record indicated the facility admitted Resident 20 on 11/23/2022. The admission Record indicated Resident 20's diagnoses included mild cognitive (ability to think, understand, learn, and remember) impairment of uncertain or unknown etiology (cause), bilateral (both sides) knee osteoarthritis, and difficulty in walking. During a review of Resident 20's MDS, dated [DATE], indicated Resident 20 had clear speech, clearly expressed ideas and wants, understood verbal content, and had severe cognitive impairments. The MDS indicated Resident 20 was not steady and only able to stabilize balance with staff assistance for moving from a seated to standing position, walking, and surface-to-surface transfers. During a review of Resident 20's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], indicated Resident 20 required moderate assistance (25-50% physical assistance) to ambulate (walk) 20 feet using a rollator walker (assistive walking device with four wheels, a seat, and brakes). The PT recommendations included a restorative nursing program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) for ambulation. During a review of Resident 20's physician's orders, dated 3/30/2023, included RNA for ambulation three times per week with rollator walker and moderate assistance. During a review of Resident 20's physician's orders, dated 4/4/2023, indicated to discontinue RNA for ambulation three times per week with rollator walker and moderate assistance. During a review of Resident 20's physician's orders, dated 4/4/2023, indicated an RNA transfer program three times per week for sit to stand exercises using grab bars. During a review of Resident 20's Restorative Nursing Assistant Flow Sheet (record of RNA sessions) for 4/2023 and 5/2023 did not indicate Resident 20's RNA program for sit to stand exercises using grab bars. During a review of Resident 20's physician's orders, dated 5/15/2023, indicated to discontinue RNA for sit to stand exercises using grab bars. Further review of Resident 20's physician's orders, dated 5/16/2023, indicated to perform active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) to both legs three times per week as tolerated. During an interview on 5/25/2023, at 10:58 am, Restorative Nursing Aide 2 (RNA 2) stated, Resident 20 performed sit to stand transfers with RNA 2 using the rollator walker. RNA 2 stated, Resident 20 complained of increased knee pain and could not perform the sit to stand exercise even after being given pain medications. RNA 2 stated, Resident 20's RNA orders were recently changed to AAROM for both legs. During a concurrent interview and record review on 5/25/2023, at 2:33 pm, with the DOR, the DOR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 10 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reviewed Resident 20's clinical record. The DOR stated, the PT Discharge summary, dated [DATE], recommended RNA for ambulation. The DOR stated, Resident 20's physician's orders for RNA ambulation was discontinued on 4/4/2023 due to pain in both knees. The DOR stated, Resident 20's RNA order was changed on 4/4/2023 to perform sit to stand transfers. The DOR reviewed Resident 20's RNA Flow Sheet for 4/2023 and 5/2023. The DOR stated, Resident 20's RNA Flow Sheet did not include any documentation for sit to stand transfers. The DOR stated the sit to stand transfers were not completed if it was not documented. During a concurrent interview and record review on 5/26/2023, at 9:16 am, with the DMR, the DMR stated, Resident 20's clinical record did not have any documentation that indicated RNAs performed sit to stand exercises with Resident 20. During a review of the facility's undated P&P for Activities of Daily Living (ADLs) indicated the facility will ensure a resident's abilities in ADLs do not deteriorate unless unavoidable which included a resident's ability to transfer and ambulate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 11 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 ensure, for one of one sampled resident (Resident 4), an adequate supply of oxygen (02 [a colorless, odorless, tasteless gas essential for living]) in Resident 4's portable oxygen cylinder tank. Residents Affected - Few This failure had the potential to result in the oxygen cylinder tank to run out of oxygen, no delivery of supplemental oxygen, and hypoxia (an absence of enough oxygen or low level of oxygen in the tissues to sustain bodily functions) to Resident 4. Findings: During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was originally admitted on [DATE] and last admitted on [DATE] with multiple diagnoses including right heart failure, hypertension (high blood pressure), and dependence on supplemental oxygen. During a review of Resident 4's History and Physical Examination (H&P), dated 9/24/2022, the H&P indicated, Resident 4 was alert but confused, could make immediate needs known, but was unable to make complex medical decisions. During a review of Resident 4's Care Plan (CP), initiated 9/26/2022, revised 4/14/2023, the CP indicated, Resident 4 was at risk for respiratory distress. The interventions included oxygen at 2 LPM (Liters per Minute, unit of measurement) via nasal cannula ([NC] a device consisting of a lightweight tubing used to deliver supplemental oxygen), may titrate (slowly increase) up to 4 LPM. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/3/2022, the MDS indicated, Resident 4 was severely impaired with cognitive skills (ability to think and reason) for daily decision making. During a review of Resident 4's Order Summary Report (OSR), with active orders as of 5/1/2023, the OSR indicated, an active order dated 11/7/2022 for oxygen at 2 LPM via NC and titrate up to 4 LPM every shift continuously to maintain oxygen saturation (the amount of oxygen you have circulating in your blood) level equal or greater than 92%. During a review of Resident 4's Treatment Administration Record (TAR), dated May 2023, the TAR indicated, Resident 4 was receiving oxygen at 3 LPM by NC. During a review of the facility's in-service lesion plan titled, Following MD Orders for Oxygen, dated 1/30/2023, the in-service indicated, oxygen tanks should be checked every shift and as needed during rounds and changed as needed. During a review of Resident 4's physician Progress Notes (PR), dated 5/3/2023, the PR indicated, Resident 4 was being followed by the physician for chronic (a condition persisting for a long time or constantly recurring) right heart failure with oxygen dependence and delivered by nasal cannula. During a concurrent observation and interview on 5/23/2023, at 11:00 a.m., with Licensed Vocational Nurse 4 (LVN 4), in the activities living room, Resident 4 was sitting up on a wheelchair in front of a table with a puzzle in front and two other residents along with the Life Enrichment Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 12 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 (LED) were present. Resident 4 was awake and alert but confused. Resident 4 was receiving oxygen at 2 LPM by NC and the pressure gauge needle of the portable oxygen cylinder indicated REFILL. LVN 4 stated, it looks like it should be changed. LVN 4 stated, Resident 4 may not be getting enough oxygen and this could cause confusion and lack of oxygen to the brain. LVN 4 stated, the facility did not have a Respiratory Therapist (RT, member of a health care team that evaluates, treats and cares for patients with breathing and cardio-respiratory problems). LVN 4 stated, I will get a new tank. During an interview on 5/26/23, at 7:25 a.m., with the Director of Nursing (DON), the DON stated, there was a little bit of oxygen left when the portable oxygen cylinder indicated REFILL. The DON stated, the nurses should have checked it because if the cylinder goes empty, it caused lack of oxygen to the resident. During a review of the facility's undated policy and procedure (P&P) titled, How to Use an Oxygen Tank, the P&P indicated, check the pressure gauge to verify that there is enough oxygen in the tank (full is approximately 2,000 psi [pounds per square inch]). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 13 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0759 Ensure medication error rates are not 5 percent or greater. 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 its medication error rate was not five percent or greater. Residents Affected - Few The facility had 8 total medication errors in 28 opportunities during medication administration which yielded in a 28.57 % medication error rate. Eight medications due at 8 am., for one of four sampled residents (Resident 30) were administered late. This failure had the potential to result in an inadequate amount of the prescribed medications in Resident 30's bloodstream and a decline in Resident 30's physical well-being. Findings: During a review of Resident 30's admission Record (AR), the AR indicated, Resident 30 was originally admitted to the facility on [DATE] and last admitted on [DATE] with multiple diagnoses including hypertension (high blood pressure), glaucoma (a group of eye conditions that can cause blindness) and macular degeneration (an eye disease that causes vision loss). During a review of Resident 30's History and Physical Examination (H&P), dated 9/7/2022, the H&P indicated, Resident 30 was alert but confused, could make immediate needs known, but was unable to make complex medical decisions. During a review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/13/2023, the MDS indicated, Resident 30 was severely impaired with cognitive skills (ability to think and reason) for daily decision making. During a review of Resident 30's Order Summary Report (OSR), with active orders as of 5/1/2023, the OSR included the following medications (administered by Licensed Vocational Nurse 3 (LVN 3) on 5/25/2023): 1. Artificial Tears Solution 1.4% (Polyvinyl Alcohol) Instill 1 drop in both eyes four times a day for dry eyes. 2. Cholecalciferol Tablet give 1 tablet by mouth one time a day for supplement Vitamin D3 1000 unit. 3. Cyanocobalamin Tablet 1000 MCG (micrograms, unit of measurement) give 1 tablet sublingually (administered under the tongue) one time a day for supplement. 4. Irbesartan (used to treat high blood pressure) Tablet 150 MG (milligram, unit of measurement) give 1 tablet by mouth one time a day for HTN, hold if SBP (systolic blood pressure, pressure in the arteries when the heart beats) less than 120 or DBP (diastolic blood pressure, pressure in the arteries when the heart rests and between beats) less than 60. 5. Miralax Powder 17 GM (grams, unit of measurement)/scoop (Polyethylene Glycol 3350), give 17 grams by mouth one time a day for bowel management. Mix with 8 ounces (oz, unit of measurement) of water and hold for loose stools. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 14 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0759 Level of Harm - Minimal harm or potential for actual harm 6. PreserVision AREDS 2 Capsule (Multiple Vitamins-Minerals) give 1 tablet by mouth two times a day for eye vitamin with minerals. 7. Senna Plus Tablet 8.6-50 MG (Sennosides-Docusate Sodium) give 1 tablet by mouth two times a day for bowel management, hold for loose stools. Residents Affected - Few 8. Urinary Tract Infection (UTI, an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]) -Stat Liquid (Cranberry-Vitamin C-Insulin) give 30 ML (milliliters, unit of measurement) by mouth one time a day for UTI prevention. During a medication administration observation on 5/25/2023, at 10:39 am., LVN 3 prepared the following medications for Resident 30: 1. Artificial Tears (eye drops used for dry eyes) 2. Vitamin D3 ([Cholecalciferol] a supplement that helps your body absorb calcium) 3. Vitamin B ([Cyanocobalamin] a supplement that helps your body produce red blood cells) 4. Irbesartan 5. PreserVision (vitamin used for moderate to advanced age-related macular degeneration [AMD, an eye disease that can blur the central vision]) 6. Senna (used to relieve occasional constipation) 7. Polyethylene powder ([MiraLax powder] used to treat occasional constipation) 8. UTI-Stat liquid During a concurrent observation, interview, and record review on 5/25/2023, at 10:55 a.m., with LVN 3, LVN 3 stated, Resident 30's medications were due at 8 am., and the time, it's 10:55 a.m. Resident 30's Medication Administration Record (MAR), dated May 2023, was reviewed and indicated, the medications administered were due at 8 am. LVN 3 stated, medications were to be administered an hour before and an hour after the due time. LVN 3 stated, Resident 30's did get the medications on time. LVN 3 stated, medications should always be given on time as prescribed [by the physician] especially if residents (in general) required other medications to be administered. During an interview on 5/25/2023, at 12:14 pm., with the Assistant Director of Nursing (ADON), the ADON stated, the facility was to administer medications one hour before to one hour after the due time. The ADON stated, it was important to give medications timely to avoid any complications, change of conditions, errors, and for resident (in general) safety. During a concurrent interview and record review on 5/26/2023, at 3:06 pm., with LVN 3, Resident 30's May 2023 MAR was reviewed. The MAR indicated, the medications administered by LVN 3 at 10:39 am. were administered at 8 am., (check mark and LVN 3's initials to indicate administration). LVN 3 stated, the MAR showed the time medications were due, but did not show the time the medication was administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 15 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0759 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's undated Medication Pass Times (MPT), the MPT indicated, medications ordered QD (one time a day) were passed at 8:00 am., medications ordered BID (two times a day) were passed at 8 am. and 4 pm. During a review of the facility's undated policy and procedure (P&P) titled, Administering Medications, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. The P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Event ID: Facility ID: 055016 If continuation sheet Page 16 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure adequate meal preparation, for one of one sampled resident (Resident 284) who had requested smaller portions for lunch on 5/23/2023. The facility did not use appropriate serving utensils for Resident 284 as indicated in the facility's policy and procedure titled, Diets and Menus Modified Portions. This failure had the potential to result in a nutritional decline for Resident 284 and affect Resident 284's overall physical well-being. Findings During a review of Resident 284's admission Record indicated, Resident 284 was admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), left pubis fracture (break in pelvis bone), left acetabulum fracture (break in hip bone), and repeated falls. During a review of Resident 284's Order Summary Report, with active orders as of 5/22/2023, included a physician's order, dated 5/2/2023, indicated a regular diet, with regular texture, thin consistency, for low fat, and low cholesterol. During a review of Resident 284's Skilled Nursing Facility History and Physical, dated 5/23/2023, indicated Resident 284 was alert and oriented to person, place, and time and Resident 284's mental status was at baseline. During an observation on 5/23/2023, at 11:52 am, the Dietary Services Supervisor (DSS) was plating hot food. The DSS stated the portions were as followed: a black four-ounce scoop was used for the Swedish meatballs, pureed meatballs, rice, pureed rice, vegetables and pureed vegetables, a two ounce ladle was used for gravy and a six ounce ladle used for lentil soup and pureed soup. Resident 284 was served, smaller portions of food, with the use of the same size scoops and ladles. During an interview on 5/23/2023, at 11:59 am., the DSS stated Resident 284 requested smaller meal portions and when residents (in general) requested smaller portions, the DSS used the same size ladles and scoops, just put less on the plate, when plating the meals. The DSS stated some residents do not like wasting food or just do not eat a lot, so they ask for less. During an interview on 5/25/2023, at 10:31 am, the Registered Dietician (RD) stated, when a resident (in general) requests smaller meal portions, the RD would review the weight history, laboratory results, and medical history. The RD stated, if the resident (in general) needed more proteins or calories, the RD would review [current diet] and have a discussion with the resident to provide education and honor the request if it was safe. The RD stated when serving smaller portions, the facility was to follow a flow sheet and use a different [indicated by flow sheet] size scoop. The RD stated for example, the DSS would use a two or three-ounce scoop instead of a four-ounce scoop. The RD stated if residents requested smaller portions, then the staff serving the smaller portions needed to use serving utensils based off their nutritional assessment and Resident 284 did not have an order placed for smaller portions. The RD stated if staff were eyeballing or approximating portions, they were not honoring the resident's request. The RD stated staff could be over feeding or under feeding the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 17 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 0805 resident, the resident could be getting less nutrients which could lead to weight loss. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/25/2023, at 11:20 am, the RD stated when residents preferred and requested smaller portions, staff had to follow the facility's policy and procedure (P&P) that indicated smaller portions and use the appropriate size serving utensils. Residents Affected - Few During an interview on 05/25/2023, at 1:13 pm, the director of nursing (DON) states that residents who want smaller portions need to have it ran by dietician to make sure it's safe for them. States that if Resident 284's portions and diet aren't monitored properly she could have weight loss and lose important nutrients to help with healing, especially with her fracture. During a review of the facility's policy and procedure (P&P) titled, Diets and Menus Modified Portions, dated 3/2017, indicated modified portions may be deemed necessary for some residents to maximize their overall nutritional intake and/or pleasure with meals. The P&P indicated modified portions will be provided per resident request, dietician, or nursing staff. The P&P also indicated when a resident requests a portion size adjustment on a regular basis, this will be reflected in their care plan. The RD or designee will follow weight and food intake periodically for nutritional adequacy and adjust approaches as indicated. The P&P smaller portions chart for noon evening meal was as follows: meats- two ounces, starches (potato, rice pasta)- two ounces, casseroles- four ounces, vegetables, fruits and salads- two ounces, and desserts- half portion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 18 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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** b. During a concurrent observation and interview on 5/24/2023, at 9:09 am, in the laundry room, with Laundry Aide 1 (LA 1), LA 1 stated the facility laundered residents' personal laundry and personal bedding. LA 1 stated the soiled linen area included the area directly in front of the two washing machines. Two white laundry baskets with holes on all four sides of the basket were placed on the floor in front of the washing machines. Both white laundry baskets contained soiled clothing and were not covered. LA 1 stated the facility had a situation in the past in which the soiled clothing contained in the white laundry baskets belonged to a resident (unknown) who was unknowingly positive for Coronavirus-19 (COVID-19, highly contagious virus that can affect lungs and airways). Residents Affected - Some During a follow-up observation on 05/24/2023, at 10:14 am, in the laundry room, the two white baskets that contained dirty linen were in front of the washing machines. There were double stacked dryers directly to the right of the washing machines. A wooden clothing rack was positioned directly to the right of the top dryer. LA 1 put on a pair of disposable gloves and transferred clothing, except one vest and one undergarment, from the washer to the bottom dryer. LA 1 placed the vest and undergarment on hangers which were hung on the clothing rack. During a concurrent observation and interview on 5/24/2023, at 10:30 am, in the laundry room, with the Infection Preventionist Nurse (IPN), the IPN stated soiled linen and clothing should be contained in a bag to prevent [cross] contamination. The IPN stated soiled clothing should be contained in a bag after being sorted. The IPN observed the soiled clothes in the two white laundry baskets located on the floor. The IPN stated the soiled clothes could potentially contaminate the clean linen hung on the clothing rack. During a review of the facility's P&P titled, Personal Laundry, revised on 7/10/2003, indicated All soiled laundry must be placed directly into a closed laundry hamper bag. c. During a concurrent observation and interview on 5/23/2023, at 12:05 p.m., with CNA 7, in Resident 7's restroom, a pair of knee-high stockings were hanging on the pipe of the toilet. CNA 7 stated the knee-high stockings shouldn't be there. CNA 7 stated, the evening shift did it. They wash it cuz she use every night. CNA 7 stated, the washed knee-high stockings could get contaminated and should have been hung on the towel rack to dry. During a review of Resident 7's admission Record (AR), the AR indicated, Resident 7 was originally admitted to the facility on [DATE] and last admitted on [DATE] with multiple diagnoses including atrial fibrillation (irregular rapid heart rate), hypertension (high blood pressure), and anemia (low red blood count). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/2022, the MDS indicated, Resident 7 was moderately impaired with cognitive skills (ability to think and reason) for daily decision making. During a review of Resident 7's History and Physical Examination (H&P), dated 3/17/2023, the H&P indicated, Resident 7 was alert and able to make decisions regarding routine medical decisions and immediate needs. During a review of Resident 7's Order Summary Report (OSR), with active orders as of 5/1/2023, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 19 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 OSR included an order, dated 4/24/2023, indicated Venous ulcer to left second toe cleanse with wound cleanser pat dry apply Xeroform [absorbent dressing used for low draining wounds, maintains a moist wound environment, promotes wound healing] than gauze secure with bandage every evening shift for wound care for 14 days. During a review of Resident 7's Treatment Administration Record (TAR), dated May 2023, the TAR indicated, Resident 7 had a venous ulcer located on the left second toe that was being treated. During an interview on 5/26/23, at 12:05 p.m., with the IPN, The IPN stated, the washed pair of knee-high stockings should not be hung on the pipe of the toilet, for infection control reasons. The IPN stated, staff should hang it in a hanger, something clean, not on the pipe. During a review of the facility's undated P&P titled, Personal Laundry, revised 7/10/2020, the P&P indicated, to provide a process for the safe and aseptic handling, washing, and storage of laundry. During a review of the facility's P&P titled, Infection Prevention and Control Program, revised April 2023, indicated, to provide a safe, sanitary, comfortable environment, and help prevent the development and transmission of communicable diseases and infections. The P&P further indicated, educating staff, and ensuring that they adhered to proper techniques and procedures. Based on observation, interview, and record review, the facility failed to follow infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for two of two sampled residents (Resident 284 and 7) and for the laundry room soiled clothing in accordance with the facility's policy and procedure and federal guidelines by failing to: a. Ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 performed hand hygiene (procedures that included the use of alcohol-based hand rubs [containing 60%-95% alcohol] or hand washing with soap and water) before entering Resident 284's room, putting on gloves, and providing care to Resident 284. b. Ensure two of two laundry baskets located in the laundry room contained the soiled clothing in closed containers. c. Ensure Resident 7's pair of knee-high stockings were hung to dry in a clean area, Resident 7 had a venous ulcer (wound on leg or ankle caused by abnormal or damaged veins) located on the left second toe and was actively receiving wound treatment. These failures had the potential to result in the spread of infections throughout the facility and the development of infections to Residents 284 and 7. Findings: a. During a review of Resident 284's admission Record indicated, Resident 284 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) and type II diabetes mellitus (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 284's Skilled Nursing Facility History and Physical, dated 5/23/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 20 of 21 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 055016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount San Antonio Gardens 900 E. Harrison Ave Pomona, CA 91767 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 indicated Resident 284 was alert and oriented to person, place, and time and Resident 284's mental status was at baseline. During a review of Resident 284's care plan, initiated 5/23/2023, indicated Resident 284 was at risk for recurrent UTI's related to a history of a recurrent UTI diagnosis and antibiotic therapy. Residents Affected - Some During an observation and interview on 5/24/2023, at 3:30 pm, CNA 1 and CNA 2 put on gloves without performing hand hygiene and entered Resident 284's room. CNA 2 stated CNA 2 had just gone to the restroom and washed their hands, but CNA 2 was not able to state whether CNA 2 touched anything before entering Resident 284's room. CNA 1 stated it was important to perform hand hygiene before [performing] patient care to prevent infections. During an interview on 5/24/2023, at 3:47 pm, Licensed Vocational Nurse 1 (LVN 1) stated staff were supposed to perform hand hygiene upon entering resident rooms and before putting on gloves. LVN 1 stated the facility had to stop the spread of infection for the staff and for the residents to keep everyone safe. During an interview on 5/26/2023, at 12:05 PM, the Infection Preventionist Nurse (IPN) stated staff were supposed to perform hand hygiene before and after performing resident care, in between care, when staff got anything soiled, before putting on or removing gloves, and before and after eating. The IPN stated hand hygiene was important to prevent further infections and contamination. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 10/2015, indicated the purpose was to prevent the spread of infections. The P&P indicated that employees must wash their hands for at least 15 seconds using soap water before and after direct contact with residents and before assisting residents with personal care. The P&P indicated to use ABHR [alcohol-based hand rub] before and after direct contact with residents, after contact with a resident's intact skin and after contact with objects in the immediate vicinity of the resident. During a review of the Centers for Disease Control and Prevention (CDC)-Hand Hygiene Guidance for Healthcare Settings, reviewed 1/30/2023, indicated healthcare personnel should use or wash with soap and water immediately before touching a patient, after touching a patient or the patient's immediate environment and immediately after glove removal. https://www.cdc.gov/handhygiene/providers/guideline.html FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055016 If continuation sheet Page 21 of 21