Health inspection·May 4, 2022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to utilize standard protocols for gastrostomy (GT - a flexible tube surgically inserted into the abdomen to stomach for feeding and medication administration) tube medication administration for 1 out of 1 sampled resident (Resident 16). The facility administered ice cold water in between each medication pass and flush the GT. This deficient practice can potentially cause abdominal cramping or pain to residents. Finding: A review of Resident 16's admission Record indicated the facility admitted Resident 16 on 2/7/15 and readmitted on [DATE] with dementia (impaired ability to remember, think, or make decisions), functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 1/28/22, indicated Resident 16's cognitive skills (learning, understanding, and making sound decisions) for daily decision making were severely impaired. Resident 16 required total assistance from staff with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 16's Order Summary Report dated 10/22/21 indicated to flush feeding tube 30cc of water pre and post medication administration every shift. During a concurrent observation and interview on 5/3/22, at 9:57 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 administered medication via GT. LVN 3 administered and flushed Resident 16's GT with ice cold water (water had ice floating). LVN 3 stated it was better to use room temperature water instead of ice cold water for GT medication administration for better absorption and patient comfort. During an interview with the DON on 5/3/22, at 11:46 a.m., the DON stated the staff should use room temperature water for flushing GT. The DON stated cold water will not allow medication to dissolve appropriately and cause discomfort to the resident. A review of the facility's undated policy and procedure (P&P) titled, Medication Administration Via Gastrostomy or Nasogastric Tube, stated to use 10cc of water prior to placement of medication in cup and the enteral feeding tube should be flushed with at least 30cc of water before and after medications are administered. The facility's P&P did not indicate the temperature of the water to be administered via GT. The DON stated the facility will review and revise the P&P for Medication Administration Via Gastrostomy or Nasogastric Tube as needed with the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 2 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 adjust supplement oxygen based on the physicians' order and ensure respiratory care is provided in accordance with the resident's care plan in one out of one sampled resident (Resident 8). Residents Affected - Few This deficient practice has the potential to create an adverse effect such as dangerously high levels of carbon dioxide that can lead to worsening respiratory acidosis (a condition where there is too much acids in the body fluids) caused by the administration of high concentrations of oxygen to an already compromised respiratory function. Findings: A review of Resident 8's admission record indicated Resident 8 was admitted to the facility on [DATE] with Chronic Respiratory Failure with Hypoxia (a condition that results in the inability to effectively exchange carbon dioxide and oxygen and induces chronically low oxygen levels). A review of Resident 8's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 04/15/2022 indicated Resident 8 had severe cognitive impairment and required extensive to total dependence for activities of daily living. During observation on 05/02/2022 at 9:40 am, Resident 8 was administered 4 Liter per minute (L/min - unit of flow rate) humidified oxygen via nasal cannula. The humidified bottle was dated 04/27/2022 with no liquid inside and was inflated. Licensed Vocational Nurse 3 (LVN 3) verified the physicians order for Resident 8 was for 2 L/min via nasal cannula and to titrate up to 5 L/min for oxygen saturation (the amount of oxygen traveling through the body with the red blood cells) less than 92 %. The last oxygen saturation taken for Resident 8 on 05/01/2022 was 97 %. Oxygen saturation monitoring log from 04/24/2022 to 05/01/2022 indicated O2 sat for Resident 8 ranging from 92 % - 98 % and did not indicate the increase titration of the oxygen. [NAME] 3 further stated the danger is of giving more oxygen than the needed, placed the resident at risk of decompensation (deterioration of a structure or system that had been previously working). A review of the physician's order dated 02/02/2022 at 9:26 am, indicated to administer O2 (oxygen) at 2L/min via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) and to titrate up to 5 L/min for oxygen saturation less than 92 %, every shift for SOB (shortness of breath), desaturation. A review of Resident 8's care plan dated 04/26/2022 indicated, Resident 8 will be free from adverse effects related to the use of oxygen. It also stated to check rate of oxygen flow every shift, monitor oxygen saturation, and provide oxygen as ordered. A review of the facility's undated Policy and Procedure titled, Oxygen Administration, indicated to administer oxygen according to physicians' orders and if oxygen saturation is ordered, the licensed personnel are to ensure the use of oxygen is effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 3 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to do the following: Residents Affected - Some 1) Verify the identification of a resident prior to medication administration on one of seven sampled residents (Resident 12). 2) Ensure Hydrocodone /APAP 5-325 mg tablet (a combination of two pain medications used to treat moderate to severe pains) dispensed was accurately, accounted and documented in the Medication Administration Record (MAR) for effective pain reassessment on one of seven sampled residents (Resident 44). 3) Failed to dispose of narcotic medications according to facility protocols. These deficient practices had the potential to create medication - related adverse consequences or events such as medication errors, unrelieved pains, risks of respiratory distress, death if additional dose are given, and potential for loss, diversions and/or accidental exposures to controlled medications by staff. Findings: (1) During a medication pass observation on 05/03/2022 at 9:10 am, Licensed Vocational Nurse 4 (LVN 4) administered Resident 12's medications without checking the identification (ID) band and asking for her name. Medication Administration Record (MAR) cart left outside the room had Residents 12's photo but there was nothing to compare the residents with while LVN 4 was inside the room. During an interview on 05/03/2022 at 9:24 am, LVN 4 was asked how she verifies the resident when giving medications, the LVN stated she asks for the resident's name, checks the residents arm band and photo on the Medication Administration Record (MAR). LVN 4 stated she failed to check ID band and ask the resident for her name. A review of the facility's undated Policy and Procedure titled, Medication Pass, indicated to make sure during a medication pass, the resident was identified by ID band, photo, or by verification with another staff member. It also indicated the residents should never just be called out by name or asked for the name. (2) A review on one of two medication carts with the LVN Charge Nurse showed Resident 44's Hydrocodone/APAP 5-325 milligram (mg - a unit of measurement) was documented in the narcotic count sheet as removed on 05/03/2022 at 00:20 but did not reflect on Resident 44's MAR as given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 4 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 0755 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/04/2022 at 11:01 am, LVN 3 stated Hydrocodone/APAP tablet taken out from the narcotic drawer should also be reflected in the MAR with the exact time it was given. LVN 3 stated failure to document in the MAR can pose a risk of overdosing, if accidentally given an extra dose. LVN 3 further stated a nurse would not be able to verify the effectiveness of the pain medication given since most of the residents would not remember if they received them at a certain time of day. Residents Affected - Some During an interview on 05/04/2022 at 11:06 am with the Director of Nursing (DON), he stated pain medications taken out especially narcotics should be documented in the MAR, so they know if it was given to the resident and accounted for. Narcotic pain medications removed from the narcotic drawer poses a risk for the resident in receiving another dose if not charted in the MAR. A review of the facility's Policy and Procedures titled, Preparation and General Guidelines with an effective date of 08/2014 indicated when controlled medication was administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) Date and time of administration 2) Amount administered 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4) Initials of the nurse administering the dose on the MAR after the medication is administered. (3) During an interview on 05/03/2022 at 1:32 pm, Registered Nurse Supervisor (RNS) stated there was only 1 medication room in the facility located in Nursing Station 2. During an inspection of the medication room, on 05/03/2022, at 1:40pm, with RNS 1, a Morphine Sulfate (a controlled narcotic medication used to treat severe pain) Oral Solution 100 milligram (mg) per 5 milliliter (ml) (20 mg/ml) box was noted inside the discontinued medication bin, mixed with other non-controlled medications. The Morphine Sulfate Oral 100 mg bottle had been opened with about 29 ml out of 30ml remaining. During an interview on 05/03/2022 at 1:42pm, RNS 1 stated the Morphine Sulfate bottle should not be mixed in with other medications. RNS 1 stated for controlled substances 2 Licensed Nurses must sign and date a count sheet and return controlled substance to RNS 1 or DON for proper disposal once the medication has been discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 5 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the Controlled Drug Record (narcotic count sheet) dated 02/03/2022, indicated that on 02/03/2022, 0.25 ml of the medication was given. On the bottom of the record under Disposition of remaining doses, there was no documentation that the medication was destroyed, and no nurse signatures are present. During an interview on 05/03/2022 at 1:44pm, RNS 1 stated that the purpose of a count sheet was to have an accurate count of the controlled medication and to know if any of the controlled substance went missing. During an interview on 05/04/2022, at 7:22 am, the Director of Nursing (DON) stated, when controlled medication was discontinued the Licensed Nurse was supposed to give narcotics to the charge nurse (CN) on change of shift with narcotic count sheet, then the CN should give the medication and sheet to the DON. The DON also stated that he double checks narcotics with License Nurse and places narcotics in the DON's office under double locked drawer. The DON stated he was the only one with key to the narcotic drawer. Lastly, DON stated that the Pharmacist and DON destroy narcotics by using Drug disposal liquid RX destroyer and this process usually happens once a month. A review of the facility's Policy and Procedure titled Disposal of Medications and Medication-Related Supplies, dated 01/2013, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 6 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to ensure one of two medication carts was locked or under direct observation during a medication pass. This deficient practice had the potential for medication access to residents and unauthorized staff causing a potential for medication related harm. Findings: During an observation of medication pass on 5/3/22 at 9:05 a.m., Licensed Vocational Nurse 4 (LVN 4) provided Resident 43 privacy using the curtain, prior to administering Resident 43 medication. Medication cart 2 was located outside of resident's room, left unsupervised and unlocked resulting in accessibility of medications to unauthorized staff and residents. During an interview with LVN 4, on 5/3/22 at 9:09 a.m., LVN 4 was made aware medication cart 2 was unlocked while LVN 4 was administering medication to Resident 43. LVN 4 was apologetic and stated if the medication cart is not locked and unsupervised while passing medication, she cannot see the cart and medication can be taken from anyone in the facility. LVN 4 stated, I will lock it next time. During an interview with the Director of Nursing (DON), on 5/3/22, at 11:46 a.m., the DON stated medication carts should be locked, so only authorized staff have access to it. If medication carts are left unlocked and unsupervised, anyone could possibly take the medication. During an interview with LVN 3 on 5/3/22, at 9:57 a.m., LVN 3 stated medication carts should be locked for safety reasons. LVN 3 stated if the medication cart was left unsupervised and unlocked, anyone can have access to the medication. A review of the facility's policy and procedures, titled, Medication Storage in the Facility, effective date 04/2008, indicated, only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 7 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 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, interviews and record reviews, the facility failed to ensure residents foods are prepared according to the menu and standardized recipes when: Residents Affected - Some 1. The cook did not follow the Parmesan chicken recipe for regular, mechanical, pureed diets. 2. The cook used the same scoop on scalloped potatoes for all residents on both regular and Consistent Carbohydrate (CCHO) diets (a regulated system of eating to lose weight or control a medical condition). 3. Margarine for wheat rolls were not provided on any of the lunch trays. These deficient practices had the potential to result in an inconsistent distribution of carbohydrates to control the blood sugar level for 18 out of 47 residents that were on Consistent Carbohydrate (CCHO) diets. In addition, failure to follow the recipes had the potential to result in weight loss from inadequate caloric intake for residents on mechanical and pureed diets due to decreased quality of prepared food. Findings: (1) During a concurrent observation and interview on 05/02/2022 at 9 am, the cook was cooking on a large skillet ground meat which appeared red and bloody. When asked the type of meat, she stated it was ground beef for mechanical soft diet. When asked what was on the menu for lunch the cook stated chicken parmesan. When asked why she was cooking beef instead of chicken, she stated it was ground chicken. The cook also indicated the package has been thrown away in the main dumpster. During an observation on 05/02/2022 at 10:30 am, foods prepared for pureed and mechanical soft diet was already completed and, in the oven, together with the tray of chicken. During a tray line observation on 05/02/2022 at 12:00 pm, the chicken parmesan was noticed to look like a bone in chicken with tomato sauce. Chicken was not battered and there was no mozzarella and parmesan cheese on the chicken as indicated in the recipe. Observed the cook adding tomato sauce on top of the ground meat for mechanically soft diet trays. During a concurrent interview with [NAME] 1 and Dietary Service Supervisor (DSS) on 05/02/2022 at 12:15 pm, the cook stated she seasoned the pieces of chicken with salt and pepper, added parmesan then bake them. After 30 minutes, tomato sauce was added and returned in the oven to finish cooking. When asked if she used flour and egg batter to dip the chicken in for a crust, the cook looked at the surveyor and did not answer. The cook was also asked how she prepares the ground meat. Both [NAME] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 8 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 and DSS stated the meat was ground chicken but was unable to verify since the package was already discarded, and they could not find it. The cook also stated she took half of the cooked ground chicken and blended them with chicken broth for residents on pureed diet and adds tomato sauce on top during service. The cook also stated she added parmesan cheese in the tomato sauce. When asked if there was mozzarella cheese on the chicken, she stated she added them in the tomato sauce. Residents Affected - Some During a test tray on 05/02/22 at 12:40 pm with the DSS, the ground meat did not taste like chicken and there was no cheese flavor. The regular baked chicken was not boneless and did not have mozzarella cheese in them. During the same test tray and observation DSS agreed they will add mozzarella cheese next time and use breaded boneless chicken per menu and recipe. During an interview on 05/02/2022 at 1pm with the DSS, she stated the cook prepares the mechanical soft and puree separately due to time constraints. DSS indicated the process is the same whether the chicken was whole or grinded. DSS stated the cook added parmesan cheese in the tomato sauce. When asked if the chicken was breaded and with mozzarella, DSS answered we added parmesan cheese in the tomato sauce. A review of the facility's Policy and Procedure titled, Menu, dated 2019 indicated menus should be prepared as written using standardized recipes. The DSS and cooks are trained and responsible for the preparation and service of therapeutic diets as prescribed. A review of the Chicken Parmesan Recipe indicated the use of boneless chicken thighs with directions that included combining flour, salt, and pepper then combining beaten eggs and milk and then dipping the chicken in egg/milk mixture and into the flour mixture. It also indicated to mix parmesan and mozzarella together and top chicken with one tablespoon of the cheese mixture and one tablespoon of marinara sauce after baking the chicken for about 30 - 40 minutes before placing the chicken back in the oven and cheese melted. (2) During a tray line service observation on 05/02/2022 at 11:55 am, the cook used the same gray scoop #8 (½ cup) for scalloped potatoes to serve residents on CCHO diet and residents on regular diet. CCHO diet received ½ cup of scalloped potatoes instead of ¼ cup as indicated in the lunch menu. According to the facility's spring cycle lunch menu and recipe instructions for 05/02/2022, the following portions should be served for scalloped potatoes: ½ cup for regular portions (regular diet) and ¼ cup for regular portions (CCHO diet). During an interview and review of the facility lunch menu with Dietary Supervisor (DSS) on 5/3/22 at 9:30, the DSS stated both CCHO diet and regular diet receive the same food. During a concurrent review of the menu, the DSS stated they didn't realize that the portion for potatoes was smaller for the resident's on CCHO diabetic diet. The DSS verified it was a mistake and stated she will provide in-service to cooks and staff. A review of the facility's undated Policy and Procedure titled, Consistent Carbohydrate Diet, indicated it was designed to provide a sufficient amount of calories in a consistent distribution of carbohydrate, protein, and fat to maintain the individual at a desirable weight and/or control the blood glucose level. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 9 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 (3) Level of Harm - Minimal harm or potential for actual harm During an observation on 05/02/2022 at 11:55 am, the margarine were not provided for the wheat rolls on all resident's meal trays. Residents Affected - Some During an interview with the DSS on 05/03/22 at 9:36, she stated they forgot and will make sure residents receive the margarine with dinner roll. According to the facility's spring cycle lunch menu for 05/02/2022, 1 teaspoon (tsp) of margarine will be provided for both regular and CCHO diets together with 1 wheat roll for each. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 10 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in addition facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness when: 1) High concentration of chemical sanitizing solution used to clean kitchen surfaces which could potentially contaminate food contact surfaces. The facility was using 1 tablespoon (tbsp) of bleach per gallon instead of 2 teaspoon (tsp) per facility policy. 2) Dishwasher staff was going from dirty to clean task without changing gloves and washing hands. 3) Cook did not have fully covered hair while preparing and cooking food in the kitchen. 4) Multiple unlabeled and undated food items in the residents' dining room refrigerator with staff and residents' foods stored on the same refrigerator. These deficient practices had the potential to result in food borne illnesses and chemical contamination for residents who consume the food prepared by the facility every day. Findings: (1) During a concurrent observation and interview in the kitchen on 05/02/2022 at 9:10 am, a red bucket with liquid and wet cloth was stored on the counter next to dishwashing area. Dietary Aid (DA) stated there was a sanitizer solution inside the red bucket. DA stated she prepared the sanitizer solution in the red bucket at 8 am and used them to sanitize the food preparation counters and meal carts. DA was asked to test the chemical concentration in the red bucket. DA took a test strip and dipped in the solution for one second then compared the color on the test strip to the color code on the test strip bottle. Test strip indicator read 200 parts per million (ppm) which was above the manufacturers recommended sanitation concentration for chlorine of 50 - 100 ppm. During an interview on 05/02/2022 at 1:03 pm with the Dietary Service Supervisor (DSS), who worked in the facility for 15 years, DSS verified sanitizing agent in the red bucket was increased due to Covid by corporate and was told by county health inspector that chlorine reading should be at 200 ppm. DSS also stated their policy indicated chlorine at 200 ppm. DSS stated dinnerware sanitizing agent concentration was kept at 50 - 100 ppm. When asked what's the difference between the two, DSS stated all food contact surfaces should not have chemical contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 11 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 A review of records on chlorine sanitizer log for the month of 05/2022, indicated chlorine level should be at least 100 ppm. For 05/01/2022 and 05/02/2022 log entries indicated a 200 ppm reading. A review of the facility's undated Policy and Procedure titled, Sanitizing Equipment and Surfaces with Chlorine, indicated to fill bucket with water and chlorine solution per manufacturers guidelines using 2 teaspoons of chlorine diluted in one gallon of water. (2) During an observation on 05/02/2022 at 9 am, Dietary aid/dishwasher (DA) was noticed moving from dirty task to clean task without changing gloves and washing hands. The Dietary aid/dishwasher took out clean dishes from the dishwasher without changing gloves and washing her hands after cleaning and touching dirty utensils and dishes. During an interview with the DA on 05/02/2022 at 9:20 am, she stated she forgot and will work on making sure to change gloves and wash her hands next time to prevent contaminating clean dishes and utensils. A review of the facility's Policy and Procedure titled, Sanitation and Infection Control, dated 2019 indicated, hand washing was to be performed after handling soiled dishes and utensils. (3) During a kitchen tour on 05/02/22 at 8:56 am, the [NAME] was observed wearing a hair cap that did not completely cover the bottom part of the hair while preparing and cooking food. During an interview with the DSS on 05/02/2022 at 1:10 pm, the DSS was informed of the [NAME] not wearing a hair net instead was wearing a cap exposing the bottom parts of the hair. DSS stated she will remind the cook to wear a hair net and review Sanitation and Infection Control policy with her. A review of the facility's Policy and Procedure titled, Sanitation and Infection Control, dated 2019 indicated on personal hygiene section, a hair net or head covering which completely covers all hair should be always worn. (4) During an observation in the resident's refrigerator located inside the dining room on 05/02/2022 at 9:50 am, a sign posted on the refrigerator indicated Attention: All staff and Resident's foods inside the refrigerator are to be labeled and discarded after 3 days. During the same observation there were multiple unlabeled and undated food items stored inside the refrigerator. There were three bags of food for resident in room [ROOM NUMBER]A with no date, the bags were closed tight was not able to identify contents. There were two packages labeled with resident's room number with no date. Inside the package was cold pressed juice that was opened and half empty and a container of peanut butter in a jar. There was one bag of leftover food content not identified with a date of 04/20/2022 exceeding storage period. There was expired heavy cream and a container of tuna salad dated 04/25/2022 and a chicken chili beans dated 04/24/2022. There was a staff lunch bag and staff left over food inside the same refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 12 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 an interview on 05/02/2022 at 10:05 am, the Director of Staff Development (DSD) stated the refrigerator was for resident's outside food and staff. She also stated housekeeping empties and disinfect the refrigerator at the end of the week. DSD stated the policy indicated resident food was kept in the refrigerator for 3 days and if it was homemade should be discarded after 1 day. During the same interview the DSD verified there were multiple unlabeled and expired food items. The DSD stated staff had a refrigerator in the break room and they should not store food in the resident's refrigerator. The DSD added there was a confusion with staff food storage, and she will provide in-service. The DSD added she would remove the posted sign indicating staff and resident's refrigerator. The DSD stated she would speak with residents and family and discard all expired and not dated items. During an interview on 05/02/2022 at 10:15 am, the Director of Nursing (DON) stated the refrigerator was used to store outside food for residents. The DON stated food should be clearly labeled and dated before storing in the refrigerator. During an observation in Nurses' Station 2 on 05/02/22 at 10:17 am, there was a V8 energy drink with an expiration date of 01/18/2022, stored inside the resident's refrigerator. The DSD verified she does not know whose owned the drink. The DSD added that food and drinks from home are labeled with resident's names, room numbers, and dated. After 72 hours they are discarded, and containers saved for the family to pick up. A review of the facility's undated Policy and Procedure titled, Food from Outside Sources, indicated, foods from outside sources are discouraged due to problems with food safety and infection control, as well as control of therapeutic diet orders. Foods from outside sources are occasionally encouraged if a resident was eating poorly. Foods that are brought in should be placed in a plastic container with a tight-fitting lid, labeled with the individuals name and dated if it must be stored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 13 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to evaluate its resident population to identify the services and resources required to meet the resident's care needs. This deficient practice placed the residents at risk for lack of or delay in care and/or treatment services as needed due to not enough staffing and/or resources during daily care. Findings: A review of the Facility Assessment, dated 4/21, consisted of a facility analysis that included three parts, Resident Profile, Services and Care Offered Based on Resident's Needs and Facility Resources Needed to Provide Competent Support and Care to the Residents Every Day and During Emergencies. The analysis failed to include quantifiable data (data obtain from data sources such as RUGs [Resource Utilization Groups are significant because they are the core services provided to residents such as Rehabilitation, Extensive Services, Special Care, Clinically Complex, Impaired Cognition, Behavior Problems, and Reduced Physical Function], MDS [Minimum Data Set data are comprehensive assessments of each resident's functional capabilities and helps nursing home staff identify health problems] and resident/patient acuity tools) to describe the number of residents that require the services in facility to understand and make an analysis of the required staff needed to meet the residents needs. During an interview with Director of Nursing (DON) and Administrator (ADM) on 05/04/22 at 01:01 p.m., the ADM stated the last facility assessment tool was reviewed in 4/21 and failed to provide the staffing plan based on the resident's needs. The ADM stated there is no Policy & Procedure for the Facility Assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 14 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 Based on interview and record review, the facility failed to enforce its own policy related to infection control surveillance system by not having a data collection process to monitor residents with sign and symptoms of possible infections to reduce and control the spread of infections and/or outbreaks. Residents Affected - Few This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infections and/or outbreaks for the residents in the facility. Findings: A review of the facility's record titled Antimicrobial Tracking Log for the month of 01/22, did not indicate the number of residents monitored for signs and symptoms of possible infections without the use of antibiotics. During an interview with the Infection Preventionist (IP) on 05/04/22 at 08:14 a.m., when asked to explain the facility's infection control surveillance program, she stated the residents logged and monitored on the Antimicrobial Tracking Log were only the residents with antibiotic orders. The IP further stated she did not have a process or a log to reflect the residents with signs and symptoms of possible infections for the month 01/22 without antibiotics. The IP verified there were residents with signs and symptoms of possible infections without an order of antibiotics in 01/22. The IP stated since infectious periods are used to determine an outbreak, a data collection tool to monitor residents with signs and symptoms of possible infection was necessary. For example, Clostridioides difficile (C-diff, inflammation of the colon caused by the bacteria) has an infectious period of 7 days to determine an outbreak. A review of the facility's undated Policy and Procedure titled Infection Control indicated the following: 1. The essential elements of a surveillance system include the use of standardized definitions and listing the symptoms of infections, the use of surveillance tools such as infection surveys and data collection template. 2. An effective infection prevention and control program is necessary to control the spread of infections and /or outbreaks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 15 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement the protocol for antibiotic (a substance used to kill bacteria and to treat infections) use for 1 of 12 sampled residents (Resident 12). Residents Affected - Few This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance. Findings: A record review of Resident 12's Face Sheet, indicated an admission date of 1/25/22, with diagnoses of Sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), unspecified organism (condition is unknown). A review of the Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 2/01/22, indicated Resident 12's cognition was severely impaired and required total dependence on the staff for activities of daily living (transfer, dressing, eating, toilet use, personal hygiene, and bathing). A review of Resident 12's physician order dated 1/25/22, indicated Cephalexin Tablet (tab) 500 milligrams (mg, a unit of measurement) 1 tab by mouth three times a day for Urinary Tract Infection (UTI, infection of the urine) for 5 days. A review of Resident 12's Medication Administration Record (MAR) indicated Resident 12 received Cephalexin Tab 500 mg 1 tab by mouth three times a day for UTI (Urinary Tract Infection) for 5 days from 1/26/22 until 1/31/22. A review of Resident 12's Surveillance Data Collection Form (UTI without an Indwelling Catheter) dated 1/26/22, indicated both Criteria 1 and 2 must be present to meet the indication for the use of an antibiotic. Resident 12's screening form failed to indicate if Resident 12 meet the requirement for Criteria 1. Criteria 1 required at least one of the following sign or symptoms, such as, acute pain and/or fever, the section was left blank. During an interview with Infection Preventionist (IP) on 05/04/22 at 08:14 a.m., she stated the Antibiotic Stewardship Surveillance Screening Form was used to assess and screen residents with antibiotic orders. Resident 12 was readmitted to the facility from the hospital with antibiotics. The IP further stated the physician was notified Resident 12's was readmitted with an antibiotic order, however, the physician was not notified Resident 12's did not meet the criteria under Antibiotic Surveillance Screening Form. The IP verified Criteria 1 was left blank for Resident 12 and the screening was not complete. The IP further stated it was important for the form to be completed because a time out (when the use of the antibiotic is stopped when the diagnostic test of symptoms of resident do not support the diagnosis of infection) could be indicated after 3 days of antibiotics, especially when a resident comes back from the hospital. A review of the facility's undated policy and procedure titled Policy on Antimicrobial Stewardship Program, indicated the following: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 16 of 17 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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 0881 Level of Harm - Minimal harm or potential for actual harm The Antimicrobial Stewardship Program will focus on a coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration. 2. Residents Affected - Few A multidisciplinary inter-professional antimicrobial stewardship team supervised by Medical Director will be established to support and monitor a facility safe and appropriate use of antibiotics. 3. Implement a time-out (TO) practices, wherein the TO is considered a stop order for an antibiotic when diagnostic test of symptoms of resident do not support the diagnosis of infection. 4. Feedback will be given to physicians on their individual prescribing .antibiotics prescribe on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 17 of 17