Health inspection·April 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few come with the tray of other residents. LVN 4 stated the cart should have included all the trays of the residents that come to eat in the dining room for meals. During an interview on 4/8/25 1:10 PM with the Dietary Supervisor (DS), the DS stated they have a list of residents that go to dining room for their meals, but the list is not always updated. The DS stated the kitchen should have worked with the dining room supervising staff and kept the list updated in order to deliver trays together and timely for residents ' dignity and rights. During a review of facility's policy and procedure (P&P) titled Dining Room Audits revised in 10/2017, the P&P indicated residents are each table are served together. During a review of facility's P&P titled, Resident Rights undated, indicated that employee shall treat all residents with kindness, respect, and dignity. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 2 of 26 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 04/10/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the licensed nurse to document the accurately and timely after medications were administered to one of four residents (Resident 37) in accordance with the facility ' s policy and procedure (P&P) titled, Administering Medications, as evidenced by: Residents Affected - Few 1.Document Resident 37's medications that were scheduled at 9 AM as administered on the Medication Administration Record (MAR) before the actual medication administration. 2. Document Resident 37's ASA (Aspirin medication that thins the blood to prevent blood clot to form) that was not administered, as administered on the MAR. The deficient practices had result in Resident 37 not receiving ASA as scheduled and put him at risk for medication error, including overdosing and underdosing on medications. Findings: During a review of Resident 37's admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and atherosclerotic heart disease (build up of fat in the blood vessels on the heart, causing blockage of blood flow to the heart and leading to heart attack and stroke). During a review of Resident 37's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/27/2025, indicated Resident 37 had intact memory and cognition (ability to think and reason). The MDS indicated Resident 37 was independent with eating, required setup or clean-up assistance with oral hygiene, and supervision or touching assistance with toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 37's Physician Order Summary, dated 4/10/2025, the Physician Order Summary indicated the physician ordered: Aspirin (ASA, a drug used to treat pain, fever and reduce the risk of heart attack) 81 milligram (mg, a measurement unit) by mouth one time a day for cerebrovascular accident (CVA, also known as a stroke, which occurs when blood flow to the brain is interrupted, leading to long-term disability or death) Prophylaxis (action taken to prevent disease), starting on 1/6/2025. Metformin (a medication used to control blood sugar) 1000 mg one tablet by mouth two times a day, starting on 1/5/2025. Jardiance (a medication used to control blood sugar) 10mg one tablet by mouth in the morning, starting on 1/6/2025. Losartan (a medication used to control blood pressure) 25mg one tablet by mouth one time a day, starting on 1/6/2025. Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) by mouth one time a day, starting on 1/6/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 3 of 26 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 04/10/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Loratadine (a medication used to trat allergy symptoms) 10mg one tablet by mouth one time a day, starting on 1/6/2025. Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet by mouth two times a day, starting on 1/9/2025. Residents Affected - Few Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) instill one drop in both eyes three times a day, starting on 1/5/2025. During a review of Resident 37 ' s MAR, dated April 2025, the MAR indicated Resident 37 was to receive ASA 81 mg one tablet at 9 AM. During a concurrent observation and interview on 4/8/2025 at 8:50 AM with Licensed Vocation Nurse (LVN) 1, LVN 1 prepared seven medications listed as below: 1. Metformin (a medication used to control blood sugar) 1000 mg one tablet 2. Jardiance (a medication used to control blood sugar) 10mg one tablet 3. Losartan (a medication used to control blood pressure) 25mg one tablet 4. Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) 5. Loratadine (a medication used to trat allergy symptoms) 10mg one tablet 6. Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet 7. Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) In an interview on 4/8/2025 at 8:50 AM, LVN 1 stated Resident 37 was scheduled to receive these seven medications at 9 AM. During a review of Resident 37 ' s MAR, dated 4/8/2025, timed at 8:53 AM, the MAR was signed indicating the medications listed below were given to Resident 37 on 4/8/2025, timed at 8:53 AM ASA 81 mg one tablet Metformin (a medication used to control blood sugar) 1000 mg one tablet Jardiance (a medication used to control blood sugar) 10mg one tablet Losartan (a medication used to control blood pressure) 25mg one tablet Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) Loratadine (a medication used to trat allergy symptoms) 10mg one tablet Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 4 of 26 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 04/10/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) one drop to both eyes During an observation on 4/8/2025 at 8:53 AM, LVN 1 brought the medications into the Resident 37 ' s room and started administering the medications. Resident 37 stated he did not see ASA among the seven medications he prepared. LVN 1 stated Resident 37 was prescribed ASA by the physician to be given everyday at 9am. During an interview on 4/8/2025 at 9:24 AM with LVN 1, LVN 1 stated she signed the MAR indicating the medication was already given to Resident 37 before administering ASA on the scheduled administration time at 9AM which was not the standard of practice for documenting the medications administered. LVN 1 stated he should have singed the MAR after administering the medications. LVN 1 stated documenting medications as administered before medication administration could leading to medication error and potential harm the residents ' health. During a concurrent observation and interview on 4/8/2025 at 10:12 AM with LVN 1, LVN 1 stated she did not administer ASA to Resident 37 which was scheduled to be given at 9 AM today because she overlooked the physician ' s order. LVN 1 stated she documented ASA 81 mg one tablet as administered at 9 AM, which was incorrect. LVN 1 stated she did not double check the physician ' s order and document the medication administration after administering the medication to ensure accurate documentation. During an interview on 4/10/2025 at 1:46 PM with the Director of Nursing (DON), the DON stated the standard of practice for the licensed nurses was to sign the MAR after the medications were administered to the residents. The DON stated signing the MAR and documenting the medications as administered before passing the medications could result in the inaccurate documentation and medication error, leading to underdose or overdose of the resident, and potentially hard the residents. During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 5 of 26 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 04/10/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 staff failed to assist one of three sampled residents (Resident 9) who unable to carry out activities of daily living (ADLs) and incontinent (no control) of bladder and bowel receives assistance with perineal care and changed incontinent brief timely. Resident 9 was observed with wet incontinent brief with pink colored urine and had foul smell that was not changed from 7am to 3:10 pm on 4/7/2025. Residents Affected - Few This deficient practice had the potential to place Resident 9 at risk for infection and skin breakdown and to negatively impact Resident 9's self-esteem. Findings: During a review of Resident 9's admission Record (AR), the AR indicated that Resident 9 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and backward from the bladder into a ureter and toward a kidney), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 9's Minimal Data Sheet (MDS- a resident assessment tool) dated 2/28/25, the MDS indicated that Resident 9 was cognitively intact (a person has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the environment). the MDS also indicated that Resident 9 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) on toileting hygiene, shower/bathe self, and personal hygiene. During a review of Resident 9'a Care Plan dated 3/12/25, indicated Resident 9 had ADL/ Self-care deficits and required assistance with activities of daily living due to muscle weakness, sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract); the interventions included to assist with toileting needs and/or provide incontinent care after incontinent episodes. During an observation with the on 4/7/25 at 8:45 am, Resident 9's room had a foul that smelled like urine. Resident 9 was wearing a diaper, and a foul smell was noticed. During an observation and a concurrent interview on 4/7/25 at 3:10 pm with Resident 9, Resident 9's room smelled urine with foul smell. Resident 9 stated the last time staff changed and cleaned her was around 7 am in the morning and it is now 3pm. Resident 9 stated sometimes she had to remind staff to clean for her and to change her diaper. During an observation and concurrent interview on 4/7/25 3:10 pm with Certified Nurse Assistant (CNA) 1 stated Resident 1 smelled like a urine with foul smell when she went to Resident 9's bedside, CNA 1 stated the previous CNA did not inform her the last time Resident 9's incontinent brief was changed and when the resident was provided perineal (cleaning of the genital and anal area). Resident 1 ' s incontinent brief was observed wet with pink colored urine with foul smell when CNA 1 changed the brief. During an interview on 4/7/25 at 3:20 pm with the Treatment Nurse (TXN), the TXN stated Resident 9, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 6 of 26 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 04/10/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed frequent checking and perineal care was needed and not acceptable to leave Resident 9 with soiled foul-smell incontinent brief. During an interview on 4/10/25 at 2:20pm with the Director of Nursing (DON), the DON stated for any residents who are not able to carry out ADLs by themselves are assisted by CNAs at the level of assistance. The DON stated when the CNA assigned to Resident 9 should provided proper perineal hygiene and should have done rounding and checking around the clock. The DON stated it ' s not acceptable that CNAs did not endorse to each other of their work during shift change, and resident was left soiled and with foul smell for hours. During a review of the facility ' s policy and procedure (P&P) revised in 3/2018, the P&P indicated that residents who are unable to carry out ADLs independently will receive the services necessary to maintain good grooming, and personal hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including adequate support and assistance with hygiene, mobility, elimination, and communication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 7 of 26 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 04/10/2025 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 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 provide necessary care and interventions to prevent development or recurrence of pressure injury (PI-localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 9) who was not repositioned and turned, skin was not assessed and documented in the resident's clinical record the skin condition daily and weekly as indicated in the residents care plan, and facility ' s policy and procedures titled Prevention of Pressure Injuries. Residents Affected - Few These deficient practices placed Resident 9 and all other residents at risk for skin breakdown to develop PI or reopening of a healed PI that could lead to discomfort, pain and infection. Findings: During a review of Resident 9's admission Record (AR), the AR indicated that Resident 9 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and backward from the bladder into a ureter and toward a kidney), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 9 ' s Minimal Data Sheet (MDS- a resident assessment tool) dated 2/28/2025, the MDS indicated that Resident 9 was cognitively intact (a person has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the environment). the MDS also indicated that Resident 9 required partial/moderate assistance (Helper does less than half the effort, lifts, holds, or supports trunk or limbs, but provides less than half the effort) on rolling left and right. During a review of Resident 9 ' s Braden Scale for Predicting Pressure Injury Risk, indicated the total score was 16 (scale range 15 to 18 at risk for pressure injury). There was no documented assessment after the last note dated 12/22/2024. During a review of Resident 9 ' s Weekly Licensed Nurse Note dated 4/6/2025, indicated to prevent skin breakdown for Resident 9 the interventions included only the placement of LAL mattress. During a review of Resident 9 ' s Skin and Wound Evaluation, dated 12/20/24, indicated Resident 9 had discoloration was on right upper arm. There was no documented skin assessment after 12/20/2024, During a review of Resident 9's Care Plan dated 1/1/2025, indicated that Resident 9 was at risk to develop additional pressure sores related to history of Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) upon admission, due to wheelchair-bound (unable to walk through injury, illness, etc and relying on a wheelchair to move around). The care plan also indicated interventions included to assist with toileting needs and/or provide incontinent care after incontinent episodes; staff to assess risk by using the Wound Risk Assessment on admission, quarterly and PRN (as needed); staff will assess skin condition daily during care and with weekly body checks; staff will provide pressure relieving device/interventions as ordered. During an observation on 4/7/2025 at 3:15 pm with Certified Nurse Assistant (CNA) 1, Resident 9 ' s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 8 of 26 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 04/10/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few both buttocks were observed with skin redness approximately 5 inches in diameter. TXN stated he was not sure how often or if repositioning for Resident 9 was done today. TXN later stated he should have properly assessed Resident 9 ' s skin redness and documented the assessment, interventions, and monitoring of the skin. During an interview on 4/7/2025 at 3:55 pm with the Licensed Vocational Nurse (LVN) 5, LVN 5 stated it was the facility staff ' s responsibility to turn and reposition Resident 9 every two hours per facility-wide turning schedule. LVN 5 stated Resident 9 was on Low Air Loss Mattress (LALM-a mattress designed to prevent and treat pressure wounds) due to history of pressure injury, and due to impaired mobility, it ' s crucial to reposition Resident 9 around the clock and with adequate support. During an interview on 4/8/2025 at 12:20 pm with CNA 4, CNA 4 stated she was assigned with Resident 9 on 4/7/2025 am shift. CNA 4 stated when she finished bathing Resident 9 at around 8 am to 9 am, she cleaned and changed Resident 9 ' s diaper at around 2 pm and repositioned the resident. Resident 9 remained laying on her back from 9 am to 2 pm. During an interview on 4/10/25 at 2 pm with the Director of Nursing (DON), the DON stated , CNA 4 should have not left Resident 9 in the same position for a long time, residents would understand and accept if staff kindly offered and explained the importance of repositioning and turning in bed. The DON stated Resident 9 had a history of healed Stage 4 (four) PI so proper skin care and repositioning was very important for Resident 9 to minimize the risk of reopening PI because when it ' s open again it can deteriorate fast. During a review of the facility's Policy & Procedure (P&P) titled Prevention of Pressure Injuries revised 3/2023, indicated the following: Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living- activities such as bathing, dressing and toileting a person performs daily.) Identify any signs of developing pressure injuries (i.e. non-blanchable erythema [any abnormal redness of the skin].) For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) Moisturize dry skin daily Reposition resident as indicated on the care plan. Reposition all residents with or at risk of pressure injuries on an individualized schedule. Select appropriate supportive surfaces based on the resident ' s risk factors, in accordance with current clinical practice. Evaluate, report, and document potential changes in the skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 9 of 26 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 04/10/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to provide an environment free of accident and hazard, monitoring and supervising as indicated in the facility's policy and procedure and resident's care plan for one out of 4 residents (Resident 2) who was at risk for fall due to poor safety awareness and unable to see clearly due to an eye infection and wandering behavior (walking in places aimlessly), Resident 2 was walking in the room with eyes closed and hands outstretched, running into wall several times near the restroom area without staff present to assist or redirect the resident. This failure had the potential to result in serious physical harm, psychosocial isolation, and unmet care needs, compromising both the resident ' s safety and quality of life. Findings: During a review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] with a diagnosis of dementia (a disease that affects ability perform everyday activities, memory and thinking) , Alzheimer's disease ( a type of dementia that affects memory, thinking and behavior) and difficulty in walking with subsequent fractures (broken bone) of the right pubis ( one of three bones that make up the pelvis). During a review of Resident 2's History and Physical (H&P) dated 12/21/2024, indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/28/2025, indicated Resident 2 was not able complete the interview due to severe cognitive impairment (a decline in mental abilities that interferes with daily functioning, safety, and independence). During a review of Resident 2's Fall Risk Assessment dated 1/27/2025, indicated Resident 2 was at high risk for falls and unable to stand without assistance related to unsteady gait (unable to balance self when walking) and poor standing balance. During a review of Resident 2's Care Plans titled Fall Risk with a revision date of 11/11/2024, indicated Resident 2 was at risk for falls and injury because of dementia with a history of falling related to behavioral problems, difficulty walking, general weakness, history of falling, impaired cognition, poor safety awareness and judgment. The Care plan goal was to reduce the risk of falls and injury through appropriate interventions such as performing a fall risk assessment upon admission, quarterly, annual, and with change of condition. During a review of Resident 2's Care plans titled Dementia/ BPSD with a Revision date 11/11/2024, indicated Resident 2 was at risk for behavioral problems and confusion due to Dementia. Exhibiting restlessness, sadness, crying, inattention or indifference in her surrounding, uncooperativeness and wandering. The Care plan goal was to manage behaviors through appropriate interventions such as behavior management, consistent caregiver, and redirection as needed. During a review of Resident 2's Change of Condition Assessment Form dated 3/30/2025, it was noted that the resident had experienced a change in condition. The documentation indicated that Resident 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 10 of 26 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 04/10/2025 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 0689 was found to have eye irritation. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/7/2025 at 9:23AM, Resident 2 was walking in her room without supervision or assistance. Resident 2 was walking with eyes closed and hands outstretched, running into wall several times near the restroom area. No staff were present to assist or redirect her at the time of observation, no bed or chair alarm was heard during the incident. In a concurrent interview on 4/7/2025 at 9:25AM, with Resident 2, in the presence of the Director of Nursing (DON), the DON interpreted and interviewed Resident 2 in her native language. In an interview Resident 2 stated Yes, I need assistance with walking. I need to hold someone as a guide, I don ' t know where I ' m going. I cannot see. Residents Affected - Few During an interview on 4/7/25 at 9:37AM, the DON stated that Resident 2 has a diagnosis of dementia and was known to be a wanderer who frequently walks around the facility. The DON explained that in some cases, Resident 2 requires one to one assistance for safety and must have supervision and assistance when ambulating. The DON stated So far, we are lucky. Normally she's in activities or we keep her engaged, but if she is unwatched, she could get hurt. During a concurrent interview and record review of Resident 2's Care plans on 4/9/2025 at 11:40 AM with Infection Preventionist (IP). IP stated Resident 2 was not blind, and that her wandering behavior was due to a new onset behavioral concern related to eye irritation. IP stated she was unable to locate a care plan specifically addressing Resident 2 ' s behavior of walking with her eyes closed stating this behavior is a potential fall risk. During an interview on 4/10/2025 at 8:29AM with Licensed Vocational Nurse (LVN1), LVN 1 stated she first noticed Resident 2's eyes were bothering her approximately nine days ago and it was at this time Resident 2 began demonstrating new behaviors of walking around with her eyes closed. During an interview on 4/10/2025 at 10:05AM with Certified Nursing Assistant (CNA) 3, CNA3 stated that for approximately one week, Resident 2 has not been opening her eyes. CNA 3 stated that the resident now attempts to walk but does so with her hands extended in front of her, as if trying to feel her surroundings and when she attempts to walk, she is unable to see where she is going. CNA3 stated Resident 2 requires increased assistance and supervision due to visual impairment and states Resident 2 should have 1:1 supervision for safety. During a review of the facility ' s policy and procedure titled, Safety and Supervision of Residents Revised on 7/2017, indicated the facility strives to maintain an environment free from accident hazards and that resident safety, supervision, and assistance to prevent accidents are facility - wide priorities grounded in an individualized, person - centered approach. The policy outlines that the care team is responsible for targeting interventions to reduce resident - specific risks related to environmental hazards. This includes providing adequate supervision and assistive devices, ensuring interventions are implemented and documented, monitoring the effectiveness of those interventions, which includes ensuring consistent and correct implementation, modifying or replacing interventions as necessary and evaluation of the effectiveness of any new or revised interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 11 of 26 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 04/10/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately monitor signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of one sampled resident with suprapubic catheter (SPC- a tube that is used to drain urine from the bladder through a cut in the abdomen) was secured with anchor (a catheter securement device) as indicated in the facility ' s policy and procedure titled Catheter Care, Urinary by failing to ensure: 1. Resident 9 was monitored for presence of foul urine smell and pink urine stain in the incontinent brief (undergarment used due to incontinence (no control) bladder and bowel. 2. Resident 9 ' s suprapubic catheter was secured with an anchor to prevent or minimize dislodging. These deficient practices had the potential for Resident 9 to develop recurrent UTI and bladder trauma and receive delayed care and treatment from infection that could lead to a decline in the residents well being. Findings: During a review of Resident 9 ' s admission Record (AR), the AR indicated that Resident 9 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and backward from the bladder into a ureter and toward a kidney), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 9 ' s Minimal Data Sheet (MDS- a resident assessment tool) dated 2/28/25, the MDS indicated that Resident 9 was cognitively intact (a person has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the environment). the MDS also indicated that Resident 9 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) on toileting hygiene, shower/bathe self, and personal hygiene. During a review of a Care Plan dated 1/1/25 indicated Resident 9 was at risk for UTI due to supra pubic catheter use with interventions that included staff to monitor Resident 9 ' s urine for sediment (solid substance in the urine) cloudiness, odor, blood, and amount of output; staff will assess for signs and symptoms of UTI and will notify the physician as needed. During a review of Resident 9 ' s Physician Order dated 3/14/25, the order indicated to monitor SPC urinary drainage bag and document the following: Color, consistency, odor, hematuria (presence of blood in the urine), bladder distention (bladder stretched) , burning sensation plus(+)= presence of S/S (signs and symptoms) of UTI, zero (0)= absence of S/S of UTI. The physician ' s order also indicated to secure SPC tubing with anchor everyday shift to minimize dislodging of catheter. During a review of Resident 9 ' s Treatment Administration Record (TAR) dated from 3/14/25 through 4/7/25. The TAR indicated Resident 9 had S/S of UTI on 3/26/25, 4/2/25, 4/4/25, and 4/5/25. The TAR also indicated no S/S was noted on 4/7/25. The TAR did not indicate what specific S/S UTI was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 12 of 26 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 04/10/2025 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 0690 observed and treatments provided. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 9 ' s Catheter Assessment and Care Plan and Nursing Progress Note, had no documented evidence what the S/S UTI observed, and intervention provided on the dates 3/26/25, 4/2/25, 4/4/25, and 4/5/25 for the S/S of UTI. Residents Affected - Few During an observation and concurrent interview on 4/7/25 at 8:45 am with Resident 9 in the room, observed Resident 9 ' s suprapubic catheter with pinkish urine output, and a foul smell was noticed. Resident 9 stated she has a SPC and a nephrostomy tube (a thin catheter that drains urine from the kidney into a bag) because of an obstruction in the kidney. Resident 9 stated she cannot see her urine drainage from her laying position and have not heard anything from the nurse about her urine output. During an observation and concurrent interview on 4/7/25 at 3:05 pm in Resident 9 ' s room with Certified Nursing Assistant (CNA 1) and Treatment nurse (TXN), CNA 1 stated she noticed the smell when she walked in the room for Resident 9. CNA 1 and TXN stated Resident 9 ' s SPC was not secured and was leaking. The TXN stated a catheter anchor device should have always been applied to prevent dislodging. During an interview on 4/7/25 at 3:15 pm with TXN, the TXN stated he was not aware Resident 9 ' s SPC urinary output was pink in the morning and just found out that the pink color in the resident ' s urine was blood at around 2:15 pm. The TXN stated he would have checked Resident 9 ' s urine earlier but he had to do treatment for all other residents. During an interview on 4/7/25 at 3:35 pm with RN 1, RN 1 stated Resident 9 had recurrent infection, and went to GACH (General Acute Care Hospital) and returned same day with physician prescribed antibiotics. RN 1 stated if the nurse identified S/S of UTI, the TAR should be documented as (+), the physician should be notified, there should be interventions and more documentation about it. RN 1 it ' s every nursing staff and his responsibilities to monitor and identify S/S of UTI so not to delay care and treatment. During an interview on 4/9/25 at 12:00 pm with LVN 3, LVN 3 stated he did not find any details describing about infection related to the TAR that indicated presence of S/S of UTI on 3/26/25, 4/2/25, 4/4/25, and 4/5/25. LVN 3 stated the nurses should have completed the documentations and indicated the interventions provided. During an interview on 4/10/25 at 1:55pm with the Director of Nursing (DON), the DON stated the SPC should've have been kept secured with an anchor at all times. The DON stated CNA should have reported to charge nurse about pink urine and foul smell when she did catheter care in the morning. The DON stated Resident 9 has had history of sepsis and foul smell which is a S/S of UTI. DON stated any nursing staff assigned for Resident 9 should have the knowledge and should have identified the issue. During a review of the facility ' s policy and procedure (P&P) titled Catheter Care, Urinary, revised on 08/2022, the P&P indicated to secure catheter with catheter securement device. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician: If urine has unusual appearance (i.e. color, blood, etc.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 13 of 26 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 04/10/2025 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 0690 If signs and symptoms of urinary tract infection or urinary retention occur. Level of Harm - Minimal harm or potential for actual harm The P&P also indicated the following information should be recorded in the resident ' s medical record: The date and time that catheter care was given, character of urine such as color (straw color, dark, or red), clarity (cloudy, solid, particles, or blood) and odor. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 14 of 26 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 04/10/2025 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to administer aspirin (ASA, a drug used to treat pain, fever and reduce the risk of heart attack) 81 milligram (mg, a unit of measurement) one tablet for one of four residents (Resident 37) as ordered by the physician. The deficient practice had resulted in Resident 37 not receiving ASA as physician ' s order which put the resident at risk for cerebrovascular accident (CVA, also known as a stroke, which occurs when blood flow to the brain is interrupted, leading to long-term disability or death). Findings: During a review of Resident 37 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and atherosclerotic heart disease (build up of fat in the blood vessels on the heart, causing blockage of blood flow to the heart and leading to heart attack and stroke). During a review of Resident 37 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/27/2025, indicated Resident 37 had intact memory and cognition (ability to think and reason). The MDS indicated Resident 37 was independent with eating, required setup or clean-up assistance with oral hygiene, and supervision or touching assistance with toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 37 ' s Physician Order Summary, dated 4/10/2025, the Physician Order Summary indicated the physician ordered ASA 81 mg by mouth one time a day for CVA Prophylaxis (action taken to prevent disease), starting on 1/6/2025. During a review of Resident 37 ' s Medication Administration Record (MAR), dated April 2025, the MAR indicated Resident 37 to receive ASA 81 mg one tablet at 9 AM. During a concurrent observation and interview on 4/8/2025 at 8:50 AM with Licensed Vocation Nurse (LVN) 1, LVN 1 prepared seven medications listed as below that did not include ASA. Metformin (a medication used to control blood sugar) 1000 mg one tablet Jardiance (a medication used to control blood sugar) 10mg one tablet Losartan (a medication used to control blood pressure) 25mg one tablet Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) Loratadine (a medication used to trat allergy symptoms) 10mg one tablet Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 15 of 26 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 04/10/2025 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 LVN 1 stated Resident 37 was scheduled to receive these seven medications at 9 AM. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/8/2025 at 8:53 AM, LVN 1 brought the seven medications into the Resident 37 ' s room and started administering the medications. Resident 37 stated he did not see ASA among the seven medications and asked LVN 1 where his ASA was. LVN 1 stated Resident 37 was not taking ASA. Residents Affected - Few During a medication pass observation on 4/8/2025 at 10:12 AM, LVN 1 did not administer ASA to Resident 37. LVN 1 stated she did not administered ASA to Resident 37 which was scheduled at 9 AM today because she overlooked the physician ' s order in the MAR. LVN 1 stated when Resident 37 mentioned that ASA was missing, she should have double checked the physician ' s order to verify. LVN 1 stated not administering ASA could cause Resident 37 having a stroke. During an interview on 4/10/2024 at 1:45 PM with the Director of Nursing (DON), the DON stated the licensed nurses did not check the order and did not know the resident was taking ASA, so she did not prepare and administer AS to Resident 37 as scheduled to avoid missed medication and medication error and prevent potential adverse effects from the underdose and overdose on the residents. During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated Medications arc administered in a safe and timely manner, and as prescribed and Mcdicatio,1s are administered within one (1) hour of their prescribed time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 16 of 26 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 04/10/2025 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store medications safely, labeled with expiration or discard date and store controlled drugs (medications that can create mental and physical addiction or dependency) in a locked in compartments that are separately locked in storage of controlled drugs for two of two sampled residents receives (Residents 37 and 40) in accordance to the facility's policy and procedure (P&P) titled, Storage of Medications. by failing to ensure: 1. Resident 37 does not store two bottles of Flonase nasal suspension (a nasal spray that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) in his nightstand drawer who was not a candidate for Self Medication Adminitration. 2. Resident 40's Lorazepam (a controlled medication medications that can create mental and physical addiction or dependency used to treat anxiety [fear of the unknown]) was separately locked from other non controlled medications (not addictive or habit forming) in the refrigerator inside the medication storage room. 3. Store Novolog FlexPen and Glargine solution pen ( injectable medications given to lower the blood sugar level) with expiration or discard date in the medication storage. These deficient practices had a potential to result in accidental consumptions and result in adverse reactions (undesired effects) from medication and harms for the resident. These deficient practices also had the potential for medication theft or diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed). In addition the deficient practice could result administering expired medication with reduced potency and lead to inadequate blood sugar control. Findings: 1. During a review of Resident 37 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and atherosclerotic heart disease (a disease with build-up of fat in the blood vessels on the heart, causing blockage of blood flow to the heart and leading to heart attack and stroke). During a review of Resident 37's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/27/2025, indicated Resident 37 had intact memory and cognition (ability to think and reason) and was independent with eating, that required setup or clean-up assistance with oral hygiene, and supervision or touching assistance with toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a concurrent observation and interview on 4/8/2025 at 8:45 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 took out the paper packaging box of Resident 37 ' s Flonase from the medication cart but did not find Flonase nasal suspension in the box. LVN 1 stated Resident 37 usually kept it inside his nightstand drawer. LVN 1 stated she saw Resident 37 had Flonase in his nightstand drawer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 17 of 26 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 04/10/2025 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 yesterday. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 37's Physician Order Summary, dated 4/10/2025, indicated the physician ordered Flonase nasal suspension 50 microgram (mcg, a measurement unit) per spray one spray in both nostrils two times a day for allergic rhinitis (inflammation of the nasal lining, causing symptoms like a runny or stuffy nose, sneezing, and itching), starting 1/5/2025. Residents Affected - Some During an observation on 4/8/2025 at 9:12 AM, Resident 37 was holding two bottles of Flonase and walking from his room to the nursing station. Resident 37 told the staff that one bottle of Flonase was empty, and he needed more Flonase. During an interview on 4/8/2025 at 9:27 AM with Resident 37, Resident 37 stated he got Flonase from the nurse on 4/6/2025 and he had been administering Flonase nasal spray to himself three to four times at night. Resident 37 stated the nurse knew that he had the Flonase with him and the licensed nurses had been allowing him to administer to himself. During a concurrent interview and record review on 4/8/2025 at 10:02 AM with LVN 1, Resident 37 ' s Physician Order, dated 4/8/2025, was reviewed. LVN 1 stated there was no physician order for Resident 37 to keep his medication at bedside and self-administer medications. LVN 1 stated Resident 37 was at risk for overdosing for administering the medication too many times or underdosing for not administering it. LVN 1 stated Resident 37 ' s medication should be kept in safe place and not at the bedside drawer and only authorized staff could access it. During a concurrent interview and record review on 4/8/2025 at 4:43 PM with the MDS Nurse (MDSN), Resident 37 ' s Self Administration of Drug Assessment, dated 1/5/2025, Interdisciplinary Team Meeting (IDT) Notes, dated from 1/2025 to present, and Care Plan, dated from 4/28/2022 to present, were reviewed. The MDSN stated according to Resident 37 clinical record the resident was not a candidate to self-administer his medication, and the licensed nurses would have to administer the prescribed medications. The MDSN stated she was not aware of that Resident 37 had kept the medication at bedside and was self-administering the medication himself until the surveyor started the investigation this morning. The MDSN stated Resident 37 ' s self-storing Flonase and self-administering medication was not addressed in the IDT and no care plan was developed regarding these issues to prevent Resident 37 from harm. During an interview on 4/10/2025 at 1:47 PM with the Director of Nursing (DON), the DON stated Resident 37 was not a candidate for self-administering medication and he should not keep the medication at bedside to prevent medication error that could lead to adverse reaction from the overdose of the medication. During a review of the facility ' s P&P titled, Storage of Medications, dated 3/2023, the P&P indicated Drugs and biologicals used in the facility are stored in locked compartment under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. During a review of Resident 40 ' s AR, the AR indicated the facility originally admitted Resident 40 on 8/1/2024 and readmitted her on 10/26/2024 with diagnoses that included epilepsy (a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings and levels of consciousness) and psychosis (a state where individuals experience a loss of contact with reality). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 18 of 26 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 04/10/2025 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 - Some During a review of Resident 40 ' s MDS, dated [DATE], indicated Resident 40 had moderately impaired memory and cognition (ability to think and reason). The MDS indicated Resident 40 required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, shower/bathe self and chair/bed-to-chair transfer, and dependent with toileting hygiene and personal hygiene. During a concurrent observation and interview on 4/9/2025 at 10:54 AM with the Infection Preventionist Nurse (IPN), in the locked medication storage room, three vials of Lorazepam solution labeled with Resident 40 ' s were stored with other noncontrolled medications in a single-locked medication refrigerator. The IPN stated even though Resident 40 ' s lorazepam was stored with other noncontrolled medications, but it was double locked with the lock to the medication storage room and the lock to the medication refrigerator. During an interview on 4/9/2025 at 11:25 AM with the DON, the DON stated it was important to store the controlled medication double locked in a separate space and not to share the same assess with the noncontrolled medication, so they could track down the controlled medications and alert the staff to be cautious when handling the controlled medication to prevent medication diversion and protect residents ' property. During a review of Resident 40 ' s Physician Order Summary, dated 4/10/2025, indicated the physician ordered to administer Lorazepam injection solution 2 milligram (mg, a measurement unit) per milliliter (ml, a measurement unit) inject 0.5 ml intramuscularly (installing medications into the muscle) as needed for status epilepticus, repeat dosing five to 15 minutes after first dose, max dose two mg. During a review of the facility's P&P titled, Storage of Medications, dated 3/2023, the P&P indicated Scheduled II-V (a class of medication at high risk for both physical and psychological dependence) controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. 3. During a review of Resident 5 ' s admission Record ( AR), the AR indicated Resident 5 was originally admitted to the facility on [DATE], with diagnoses including acute respiratory failure (Lungs cannot get enough oxygen into blood), heart failure( heart cannot pump enough blood to meet the body ' s needs) and Type 2 diabetes mellitus (the body does not use insulin properly , leading to high blood sugar). During a review of Resident 5's History and Physical (H&P), dated 12/28/2024, the H&P indicated the resident had the capacity to understand and make decision and able to make decisions for activities of daily living. During a review of Resident 5's Order Summary Report dated 4/10/2025, the physician order summary indicated the physician ordered Insulin Glargine Subcutaneous (given under the skin) Solution ( insulin Glargine) Inject 14 unit subcutaneously at bedtime for Diabetes mellitus (DM 2) Rotate injection sites, starting 12/28/2024 and NovoLog Flex Pen Subcutaneous Solution Pen injector 100 UNIT/ML ( insulin Aspart )inject as per sliding scale, subcutaneously before meals and at bedtime for Diabetes mellitus( DM2), starting 12/28/2024. During a review of Resident 5 ' s Medication Administration Record (MAR) dated 4/1/2025 - 4/30/2025, indicated Novolg flex pen had been administered subcutaneously for Resident 5 before meals for blood sugars greater that 150 from: 4/2/2025 - 4/10/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 19 of 26 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 04/10/2025 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 - Some During a concurrent observation and interview on 4/10/2025 at 10:44 AM with Licensed Vocational Nurse (LVN1) a medication cart storage inspection was conducted. The following observation of expired medication were made for Resident 5: -Novolog flexPen Subcutaneous Solution Pen injector 100 Unit/Ml (Aspart) was labeled with an open date of 3/5/2025, no expiration or discard date was indicated on pen. -Glargine Subcutaneous solution Pen injector inject 14 unit subcutaneously at bedtime for Diabetes mellitus (DM 2), was labeled with an open date 3/5/2025, no expiration or discard date was indicated on pen. During the same interview on 4/10/2025 at 10:44 AM, LVN1 stated that insulin pens are valid for 28 days after opening and further stated it is the responsibility of all licensed nurses to check and monitor expiration dates. LVN 1 stated expired insulin may not have the same potency, and as a result the resident may not be treated appropriately. During an interview on 4/10/2025 at 1:50PM with Director of Nursing (DON), DON stated Novolog was expired, 9 days past the 28 days period from its open date on 3/6/2025. The DON stated the nurses have been administering expired NovoLog to the resident from 4/2/2025 to 4/10/2025. The DON stated the expired medication had the potential to lose its strength and become ineffective when administering to the resident. Administering expired NovoLog puts the resident tat risk for uncontrolled blood sugar. During an interview on 4/10/2025 at 1:53PM with Director of Nursing (DON), DON stated expired medications should be discarded immediately and replaced with unexpired medication. The DON stated the expired medication had the potential to lose its strength and became ineffective when administering to the resident. The DON stated expired medications should not be stored in the medication cart to prevent the administration of the expired medications to the residents and the potential adverse reaction from the expired medications During a review of the facility ' s policy and procedure titled Storage of Medications with a revision date of 3/2021, indicated Nursing staff are responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner. Drug containers with missing, incomplete, improper, or incorrect labels are to be returned to the pharmacy for proper labeling before being stored and discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or disposed of as indicated by facility procedures. During a review of the facility ' s policy and procedure titled Administering Medication with a revision date of 3/2023, indicated medications are administered in a safe and timely manner, as prescribed, and expiration or beyond use date on the medication label is checked prior to administering FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 20 of 26 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 04/10/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, Interview, and record review the facility failed to ensure proper food handling practices by: Residents Affected - Some Failing to prepare food in a manner to prevent food born illness by using bare hand contact while plating food. Failing to label with the Use by Date potentially hazardous food in the refrigerator and freezer. These deficient practices had the potential to result in foodborne illness for those who receive and consume food prepared from the facility kitchen. Findings: During an initial tour of the kitchen on 4/7/2025 at 8:16 AM and concurrent interview with the Dietary Supervisor (DS), there were multiple plastic cups observed labeled whole milk and juice stored in the refrigerator. The cups labeled with poured date of 4/6/2025 but did not include a use by or expiration date. Dietary Supervisor stated the date on label reflects the date the milk and juice had been poured into cups and further stated the Use by Date was not necessary. During the continuation of the kitchen tour with the DS, observed in the reach- in freezer one bag of green beans, loosely wrapped and unsealed labeled with a date of 4/1/2025, no use by date or expiration date present. Chocolate cream de la cream pie dated 3/20/2025, the pie did not indicate a use by date, or expiration date. The DS stated the food items are good for one year, but the facility use them fast. The DS further stated she really did not know the date the mentioned food items need to be used by. The DS stated she does know the facility has a list. During the continuation of the kitchen tour with the DS, observed in freezer two lunch meat in box with open date of 3/1/2025, no use by date indicated. The DS stated the facility does not put any use by date on any of the food items. During an interview on 4/7/2025 at 2:55 PM, with the DS, the DS stated a thaw by date refers only to meat products, indicating when the meat should be defrosted. The DS further stated that she does not apply expiration or use by dates to food items stored in the refrigerator or freezer. The DS stated that use by dates should be applied to food items after opening in order for staff to know when it should be used by. During an observation of tray line (physical setup and preparation of resident meals assembled and prepared for delivery) in the kitchen and concurrent interview on 4/8/2025 at 12:15 PM with Kitchen Staff 1, it was observed that staff member was plating food without wearing gloves and without washing hands. The meal being prepared included pasta, spinach, and meat sauce. Kitchen Staff 1 stated the kitchen staff are supposed to wear gloves while preparing food to serve. Staff member further stated that this practice is required for food safety and to prevent contamination. During a review of the facility ' s policy and procedure titled, Refrigerator and Freezer storage (Undated), indicated, all items stored in the refrigerator and freezer should be properly covered, dated and labeled. Frozen food removed from its original packaging must be labeled and dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 21 of 26 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 04/10/2025 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 Leftovers are to be covered, dated, and labeled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 22 of 26 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 04/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with the updated facility ' s policy and procedure (P&P) titled, Charting and Documentation, for one of three residents (Resident 52). The facility staff did not document vital signs (measurement of the blood pressure, heart rate, respiratory rate and body temperature) updated plan of care, and document the treatment and services provided completely and accurately on Resident 52 ' s clinical record with declining condition and was being considered for hospice care (end of life care) by the family and was found unresponsive on [DATE]. This deficient practice had the potential to negatively impact the delivery of services to Resident 52 and other potential residents in the facility. Findings: During a review of Resident 52 ' s admission Record (AR), the AR indicated the facility admitted Resident 52 on [DATE] with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and diabetes mellitus (A diseases that result in too much sugar in the blood). During a review of Resident 52 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 52 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 52 required substantial/maximal assistance with eating, oral hygiene, and personal hygiene, and was dependent with toileting hygiene, shower/bathe self, and chair/bed-to-chair transfer. During a review of Resident 52 ' s COC (change of condition)/Interact Assessment Form, dated [DATE] timed at 6:25 AM, the COC indicated no record of Resident 52's vital signs readings from 11:30 PM on [DATE] to 5:30 AM on [DATE]. During an interview on [DATE] at 2:42 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was assigned to take care of Resident 52 from [DATE] at 11 PM to [DATE] at 7 AM. LVN 2 stated Resident 52 ' s condition had been deteriorating. LVN 2 stated the family was planning to place Resident 52 on hospice care (end of life care) on [DATE]. LVN 2 stated Resident 52 was in a critical state that required frequent monitoring and care, so she checked the resident every hour and she performed vital signs (VS) check on the resident every two hours. LVN 2 stated Resident 52 was weak, but his vital signs were still normal parameter that did not trigger a change of condition, until the certified nursing assistant informed her that Resident 52 was not responsive at 5:30 AM on [DATE]. LVN 2 stated she did not document Resident 52 ' s VS during her shift and did not document Resident 52 ' s condition and care in the progress notes which she should have. During a concurrent interview and record review on [DATE] at 3:49 PM with the MDS Nurse (MDSN), the MDSN stated there was no recorded VS from [DATE] at 10:07 AM to the time when Resident 52 was found unresponsive on [DATE] at 5:30 AM. The MDSN stated no progress notes that documented the resident ' s condition from [DATE] at 4:31 PM to the time when Resident 52 ' s body was picked by the mortuary on [DATE] at 9:12 AM. The MDSN stated she would now know if the resident was deteriorating and what exactly happened to the resident before he was found unresponsive on [DATE] from the resident ' s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 23 of 26 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 04/10/2025 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 0842 medical record. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 5 PM with the Physician, the Physician stated she was informed about Resident 52 ' s change of condition and she had discussed with the family member regarding the option of putting the resident on hospice care during his stay in the facility. Residents Affected - Few During an interview on [DATE] at 5:20 PM with the DON, the DON stated Resident 52 was admitted to the facility on [DATE] and the physician and the family were planning to put the resident on hospice for comfort care as the resident ' s condition continued to deteriorate, but the facility did not have any documentation indicating the plan of care regarding potential comfort care and hospice. The DON stated there was no progress notes for three days before the resident expired to indicate the resident ' s deteriorating condition and the care and services provided to the resident and the family members. The DON stated the staff did not document any VS to indicating frequent monitor of the resident ' s condition before he was found unresponsive on [DATE]. The DON stated the staff should document the ongoing assessment, the updated plan of care, and the provided treatment and services completely and accurately in the medical records to reflect a consistent delivery of care for Resident 52. During a review of the updated facility ' s (P&P) titled, Charting and Documentation, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 24 of 26 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 04/10/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed implement the facility ' s policy and procedure to Certified Nursing Assistant (CNA) 1 wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during care activities for one of four sampled residents (Resident 33) who was placed on enhanced barrier precaution (EBP- an infection control measure designed to reduce transmission of multidrug-resistant organisms [MDROs-a germ that is resistant to many antibiotics.]) Residents Affected - Few This deficient practice had the potential to result in the spread to infection in the facility that could affect the well being of the residents, staffs and visitors. Findings: During an observation and concurrent interview on 4/7/25 at 10:35 am, observed CNA 1 was in Resident 33 room with a sign for EBP posting at room entrance. CNA 1 was observed inside the room not wearing PPE. In an interview CNA 1 stated she was just looking for an item for Resident 33. CNA 1 touched Resident 33 ' s nightstand drawer, the table, and touched Resident 33 in the who was sitting in the wheelchair. CNA 1 stated she touched Resident 33 and her belongings and was aware that Resident 33 was placed on EBP. CNA 1 stated she should have worn PPE as instructed by the IPN. During a review of Resident 33 ' s admission Record (AR), the AR indicated that Resident 33 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), difficulty in walking, and dysphagia (difficulty swallowing). During a review of Resident 33 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/25/24, the MDS indicated Resident 33 was cognitively intact (a person has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the environment). the MDS also indicated that Resident 33 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) on toileting hygiene, shower/bathe self, upper and lower body dressing, rolling left and right, and sitting to lying. During a review of Resident 33 ' s Physician Order dated 11/20/24, the order indicated Enhanced Barrier Precaution due to history of MDRO infection, observe proper Donning (put on) and Doffing (remove) of PPE and encourage good hand hygiene encourage. During an interview on 4/10/25 at 11am with the Infection Preventionist Nurse (IPN), the IPN stated if the CNA was just looking for items for the resident, he or she was not required to wear PPE. The IP stated the CNA followed the poster for EBP that indicated Wear gloves and a gown for the following high contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. During an interview on 4/10/25 at 1:55pm with the Director of Nursing (DON), the DON stated the CNA should have worn PPE not just according to what the poster indicated, PPE was necessary for direct care but also applied to situations as the resident ' s bedside and surroundings likely contaminated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 25 of 26 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 04/10/2025 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 by the resident. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s policy and procedure (P&P) titled Enhanced Barrier Precaution undated, the P&P indicated to perform hand hygiene, wear gowns and gloves while performing the task associated with residents who require EBP including any care activity involving contact with environmental surfaces likely contaminated by the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055135 If continuation sheet Page 26 of 26