Health inspection·October 7, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 150's clinical record, the admission Record indicated Resident 150 was admitted to the facility on [DATE], with diagnoses which included, chronic kidney disease (gradual loss of kidney function), hyperlipidemia (excessive fat in the blood), anemia (not enough red blood cells in the blood) and bilateral cataracts (a condition which causes blurry vision). During a concurrent observation and interview on October 4, 2022, at 10:16 AM, in Resident 150's room, Resident 150 was sitting on her wheelchair, watching television. Resident 150 stated she had an upcoming appointment with Ophthalmologist (eye doctor who performs medical and surgical treatments for eye conditions), due to her diagnosis of cataracts. A review of Resident 150's Order Summary Report, dated October 5, 2022, indicated Resident 150 had an Opthalmology appointment on November 26, 2022, due to eye cataract. During a concurrent interview and review of Resident 150's medical records, with the MDS Nurse, on October 5, 2022, at 4:11 PM, the MDS Nurse was not able to find documented evidence to indicate that a care plan was initiated for Resident 150's diagnosis of cataract. The MDS Nurse stated it must be care planned. During a concurrent interview and record review with the MDS Nurse, on October 5, 2022, at 4:30 PM, the MDS Nurse reviewed the facility's policy and procedure (P&P) titled, Policy and Procedure on Formulation of Plan of Care, revised December 8, 2008, which indicated, . In order to attain and to meet this standard set forth by the facility a plan of care for each admitted individual resident will be formulated. Plan of care will be based on comprehensive assessment of resident within 7 days upon admission, quarterly, annually and as often as needed. The MDS Nurse stated the facility did not follow the policy. Based observation, interview, and record review, the facility failed to develop a comprehensive and personalized care plan to address the needs and goals for two of 24 sampled residents (Residents 31 and 150) when: 1. Resident 31 did not have a personalized care plan for communication. 2. Resident 150 did not have a care plan for diagnosis of cataracts (a condition which causes blurry vision). These failures had the potential to prevent the resident's medical and psychosocial needs from being met. Findings: 1. During a record review of Resident 31's medical record, the admission Record (contains demographic and medical information), indicated Resident 31 was admitted to the facility on [DATE], with diagnoses which included dysphagia (unable to, or having difficulty swallowing), hypertension (high blood pressure levels), and cerebral infarction (lack of blood supply to the brain). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 2 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on October 4, 2022, at 12:56 PM, Resident 31 was in bed, using simple and small words in English, combined with hand gestures, in an attempt to communicate with staff who came into the room. No communication aides were seen at bedside. During an interview with a Certified Nursing Assistant (CNA 1) on October 4, 2022, at 1:01 PM, CNA 1 stated Resident 31 was primarily Mandarin speaking, and she attempts to communicate with staff by using a few simple words in English, accompanied with hand gestures. During a concurrent interview and record review with the Minimum Data Set (MDS) Nurse, on October 6, 2022, at 1:44 PM, Resident 31's care plan At Risk for Communication Problem, dated May 21, 2021, was reviewed. The MDS Nurse confirmed the care plan for communication had not been personalized, since most recent comprehensive quarterly assessment completed on August 12, 2022. The MDS Nurse further stated the expectation was to see interventions addressing the primary language spoken by the resident, if it was a foreign language, and what communication tools were to be used. The MDS Nurse verified neither of those interventions were in Resident 31's current care plan. During a concurrent interview and record review with the Director of Nurses (DON), on October 7, 2022, at 10:38 AM, the facility's policy and procedure (P&P) titled, Reduction of Communication Barriers, dated December 2004, the P&P indicated, Methods instituted to aid the resident in communicating their needs will be identified in the resident's plan of care. The DON confirmed they did not follow their policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 3 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to increase range of motion (measurement of how far you can move a specific joint or other body part) or to prevent further decrease in range of motion for one of three sampled residents (Resident 38), when the Restorative Nursing Assistance (RNA) active range of motion (A/AROM) program was not being provided to Resident 38, as per physician orders. This failure had the potential to decrease Resident 38's range of motion and could have resulted in worsening of contractures and mobility. Findings: During a concurrent observation and interview, on October 4, 2022, at 9:00 AM, Resident 38 was observed to be in bed, unable to move her right arm. Resident 38 stated she was not getting any exercises done. A review of Resident 38's clinical record titled admission Record, (a document containing clinical and demographic data) indicated an admission date of November 15, 2008, with the diagnoses of hemiplegia (unable to move one side of the body) affecting the right side, cerebral infarction (not enough oxygen to the brain), and muscle wasting. A review of the Physical Therapy Treatment Encounter Note (s), dated August 8, 2022, at 7:15 AM, by the PT, indicated, .Resident seen for her last skilled P.T. [Physical Therapy] session today. Please see PT DC [discharge] summary for DC status . Resident to be referred to RNA program for maintenance. Resident aware and agreeable to this plan . A review of the Order Summary, dated August 9, 2022, indicated RNA A/AROM program to all extremities QD [every day] 3 x [times]/ week as tolerated every day shift on Mon, Wed, Thu. During a concurrent interview and record review, on October 6, 2022, at 9:15 AM, with Restorative Nursing Assistant (RNA 1), RNA 1 reviewed Resident 38's Order Summary, dated August 9, 2022, and stated that Resident 38 did not receive any RNA A/AROM therapy. During a concurrent interview and record review, on October 6, 2022, at 9:30 AM, with the PT, the PT reviewed, Physical Therapy Treatment Encounter Note (s), dated August 8, 2022. The PT stated Resident 38 was supposed to be on RNA A/AROM program after August 8, 2022, but has not received the treatment. During a review of the facility's policy titled, POLICY AND PROCEDURE IN R.N.A. REFERRAL, dated November 2018, the policy indicated, It is the policy of the facility to provide rehabilitative services and a restorative nursing program for residents to prevent deterioration and to achieve and maintain optimal levels of functioning and independence . 6. Restorative assistant carries out program in according to the written plan of care and document after each R.N.A. therapy to provide to the resident. Weekly summaries are documented for each resident in R.N.A. program . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 4 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube - a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented for one resident (Resident 39) reviewed for G-tube. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise Resident 39's health. Findings: During a review of Resident 39's clinical record, the admission Record (contains demographic and medical information), indicated Resident 39 was admitted to the facility on [DATE], with diagnoses which included, hemiparesis following a cerebrovascular disease affecting left dominant side (paralysis on left side of body due to a stroke), dysphagia (difficulty swallowing), and gastrostomy status (a surgical operation for making an opening in the stomach). During a review of Resident 39's Order Summary Report, it indicated an order, dated June 13, 2022, Check Residual QS [every shift]. Hold if > [more than] 100 cc [cubic centimeter] x [for] 1 hour and Check tube site q [every] shift. A medication administration observation for Resident 39 by a Licensed Vocational Nurse (LVN 1) was conducted on October 6, 2022, at 6:09 AM, in Resident 39's room. Resident 39 was lying in bed, watching television, with the head of the bed elevated. LVN 1 attached a syringe into the G-tube, poured water and administered Pepcid (medication to treat acid reflux) 20 mg (milligrams -unit of measurement) and proceeded to flush the G-tube with 100 mL (milliliters - unit of measurement) of water. LVN 1 did not check for placement of the G-tube site or residual (fluid/contents that remain in the stomach). LVN 1 stated she needed to check for placement and residual before administering medication via G-tube, but she forgot to do it. During a concurrent interview and record review with the Assistant Administrator (Admin 2), on October 6, 2022, at 6:45 AM, the Admin 2 reviewed the facility's policy and procedure (P&P) titled, Enteral Administration - Nasogastric, Gastric & Jejunostomy, revised December 2004, which indicated, .8. Verify for correct positioning of tube by directing air and auscultation with a stethoscope or by aspirating gastric contents. The Admin 2 stated the staff did not follow the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 5 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 properly record and account for a medication removed from one of 12 Emergency Kits (E-kit- secure box kept with medications inside for urgent use). This failure had the potential to cause medications to not be readily available for resident during an urgent situation in a highly vulnerable population of 49 residents. Findings: A medication storage inspection was conducted with a Registered Nurse(RN 1) on October 6, 2022, at 7:50 AM. One non-antibiotic (medications that are not in the antibiotic category) oral emergency kit was observed to have been opened for use and re-sealed with black ties. RN 1 re-opened the emergency kit and three blank record sheets were seen inside. There was no record of what medication had been used. RN 1 stated when a medication is used, it should be documented on the record sheet inside of the kit. RN 1 confirmed one tablet of Coumadin (type of blood thinner medication) 5 milligram (mg - unit of measurement) had been removed from the emergency kit. During an interview with the Director of Nursing (DON), on October 6, 2022, at 8:10 AM, the DON stated the expectation was for the emergency kit record sheets to be an accurate account of what medications have been removed for administration to residents. The DON also stated these sheets should be kept inside the emergency kits once they have been filled out. During a concurrent interview and record review. on October 6, 2022, at 1:23 PM, with the DON, the facility's undated policy and procedure (P&P) titled Emergency Kit (E-Kit) Use was reviewed. The P&P indicated, Records will be completed according to Title 22 regulations, which includes documentation in the E-kit log and the E-kit drug card inside the kit. The DON stated they did not follow their policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 6 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 - Many 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 maintain professional standards for food service safety when two sinks in the kitchen did not have an air gap (separation of the drainpipe on a sink to prevent backflow of contaminated water during negative pressure). This failure had the potential to expose 48 highly vulnerable residents who received food from the kitchen to food-borne illness (food poisoning). Findings: During a concurrent observation and interview, with the Dietary Services Supervisor (DSS), in the kitchen, on October 4, 2022, at 8:15 AM, two sinks, one food preparation sink and one dishwashing sink, did not have an air gap. The DSS confirmed the sink drainpipes did not have air gaps. During a concurrent interview and record review, with the DSS and the Maintenance Supervisor (MS), on October 6, 2022, at 2:28 PM, the DSS and the MS reviewed a document titled ACCIDENT PREVENTIONSAFETY PRECAUTIONS, dated December 2014, which indicated .Food preparation sinks . and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink .An air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. The DSS and the MS stated both sinks should have an air gap. A review of the FDA Federal Food Code 2017 5-202.13, indicated, Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 7 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of three outside dumpster lids were completely closed. Residents Affected - Many This failure had the potential to attract vermin (pest or animals that spread diseases) in a facility that cares for 49 medically compromised residents. Findings: During a concurrent observation and interview, on October 4, 2022, at 11:12 AM, with the Maintenance Supervisor (MS), the outside garbage storage area was inspected. There were three outside dumpsters. One of the outside dumpster's lid was not closed completely. It was observed to be propped open with a long metal bar. There were plastic forks, straws, sugar packets, creamer, and milk containers on the ground. The MS stated the garbage dumpster should not be propped open and the outdoor garbage storage area should be clean and free of trash. A review of the facility's policy and procedure (P&P) titled, Food Related Garbage and Rubbish Disposal, dated December 2014, indicated, .7. Outside dumpsters provided by garbage pick up services will be kept close and free of surrounding litter. During a review of the FDA Federal Food Code, 2017, it indicated in 5-501.11 Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 8 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 - Some 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** 2. During a review of Resident 8's clinical record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included, type 2 diabetes mellitus, end stage renal disease (condition in which kidneys are not working), and hyperlipidemia (excessive fat in the blood). During an observation on October 6, 2022, at 7:20 AM, Resident 8 was sitting in her wheelchair, eating breakfast. Resident 8 stated she was leaving for her dialysis treatment (procedure to remove waste products and excess fluid from the blood). A concurrent interview and record review with the Director of Nursing (DON) was conducted on October 6, 2022, at 3:12 PM. The DON reviewed Resident 8's September 2022 Medication Administration Record (MAR), which indicated the following missing documentations: a. Amlodipine Besylate (medicine to treat high blood pressure) Tablet 5 MG by mouth one time a day, to be given at 9:00 AM, for hypertensive kidney disease, was left blank on September 15 and September 29. b. Hydralazine HCl [hydrochloride] (medicine to treat high blood pressure)Tablet 10 MG by mouth every 8 hours, to be given at 6:00 AM, 2:00 PM and 10:00 PM for hypertensive kidney disease, was left blank on September 15 at 2:00 PM, September 23 at 2:00 PM, September 26 at 2:00 PM and September 29 at 2:00 PM. c. Clonidine HCl [hydrochloride] (medicine to treat high blood pressure) Tablet 0.1 MG by mouth every 6 hours, to be given at 12:00 AM, 6:00 AM, 12:00PM and 6:00 PM for hypertensive kidney disease, was left blank on September 15 at 12:00 PM and September 29 at 12:00 PM. The DON stated there should not be blank spaces in the MAR and it was the licensed nurses' responsibility to document in the MAR after administering medications. During an interview with a License Vocational Nurse (LVN 3) on October 7, 2022, at 8:00 AM, LVN 3 stated licensed nurses must document in the MAR after administering medications. LVN 3 further stated If it is not documented that means is not done. During a concurrent interview and record review with the DON, on October 7, 2022, at 9:48 AM, the DON reviewed the facility's policy and procedure (P&P) titled, Policy and Procedure in Medication Administration, revised August 2015, which indicated, .12. Medications must be immediately charted following the administration by the license nurse who administered the medication. The DON stated the facility did not follow the policy. Based on observation, interview, and record review, the facility failed to ensure accurate and complete documentations when: 1. Resident 249's Physician Orders for Life-Sustaining Treatment (POLST- medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for themselves) did not have any dates next to the signature of the Physician and Resident 249. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 9 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 2. Resident 8's Medication Administration Record (MAR) has no documentation of licensed nurses' initials when three blood pressure medications were administered. Level of Harm - Minimal harm or potential for actual harm 3. There was no POLST in Resident 14's medical record. Residents Affected - Some 4. There were missing documentations of Resident 44's routine pain medication administration. These failures had the potential for unmet resident care needs due to incomplete and inaccurate medical information. Findings: 1. During a review of Resident 249's clinical record, the admission Record (contains demographic and medical information) indicated, Resident 249 was admitted to the facility on [DATE], with diagnoses which included, fracture of the right femur (broken thigh bone), type 2 diabetes mellitus (high sugar levels), and hypertension (high blood pressure). During a review of Resident 249's undated POLST, the POLST was filled out and signed by the Physician and Resident 249. Further review indicated it did not have any dates to specify when the Physician and Resident 249 signed the POLST. During a concurrent interview and record review, with the Medical Records Director (MRD), on October 5, 2022, at 8:19 AM, the MRD reviewed Resident 249's POLST and stated there should have been dates where the Physician and Resident 249 signed. During a concurrent interview and record review, with the Assistant Administrator (Admin 2), on October 5, 2022, at 10:30 AM, the Admin 2 reviewed Resident 249's POLST and reviewed the policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST) or Request Regarding Resuscitative Measures Form, dated January 2015, indicated, .The form is to be signed and dated by the resident with capacity . The Admin 2 stated the policy was not followed because of the missing dates beside the signatures of the Physician and Resident 249. 3. During a record review of Resident 14's medical record, the admission Record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included cardiac arrhythmia (irregular heartbeat), and hypertensive heart disease (high blood pressure). Further review indicated there was no Physician's Orders for Life Sustaining Treatment (POLST) Form in the chart. During an interview with the MRD, on October 5, 2022, at 12:26 PM, the MRD stated she could not find Resident 14's POLST. The MRD stated the original POLST Form was mailed to the physician upon Resident 14's admission three months ago, and she denied having a copy kept in the chart in the meantime. During a concurrent interview and record review with the MRD, on October 6, 2022, at 1:40 PM, the facility's policy and procedure (P&P) titled, Physician's Orders for Life Sustaining Treatment (POLST) or Request Regarding Resuscitative Measures Form, dated January 2015, was reviewed. The P&P indicated a copy of the POLST is to be retained in the resident's health record. The MRD confirmed there was no POLST Form in Resident 14's medical record, and stated they did not follow their policy. 4. During a record review of Resident 44's medical record, the admission Record indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 10 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 - Some 44 was admitted to the facility on [DATE], with diagnoses which included pain, neuropathy (numbness and pain in the hands and feet), and restless leg syndrome (uncontrollable urge to move the legs). During further record review of Resident 44's medical record, the Order Summary Report (contains physician's orders), dated August 19, 2022, indicated the physician had ordered Norco (pain medication) 5/325 mg Give 1 tablet by mouth every 8 hours for pain management. During a concurrent interview and record review with a Registered Nurse 1 (RN 1), on October 7, 2022, at 9:21 AM, Resident 44's September 2022 MAR was reviewed. The MAR indicated there was no documentation of administration for routinely scheduled Norco 5/325mg for three separate administration times: September 15, 2022 at 2:00 PM, September 23, 2022 at 2:00 PM, and September 29, 2022 at 2:00 PM. RN 1 stated there should not be any missing documentation in the MAR. RN 1 further stated missing documentation or signatures on the MAR indicate that the medication was not given. During a concurrent interview and record review with the DON, on October 7, 2022, at 10:34 AM, the facility's policy and procedure (P&P) titled Policy and Procedure in Medication Administration, dated August 2015, was reviewed. The P&P indicated Drugs must be administered in accordance with the written orders of the attending physician. The DON stated they did not follow their policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 11 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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** 1.d. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included hypertensive chronic kidney disease (condition happens when the arteries that transport blood to your kidneys get smaller), and cellulitis of right upper limb (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Residents Affected - Some During a medication administration observation for Resident 8, by a Licensed Vocational Nurse 2 (LVN 2), on October 4, 2022, at 12:10 PM, in Resident 8's room, LVN 2 took out Resident 8's medications from the cart. LVN 2 placed the medications in a medication cup and poured Resident 8 a cup of water. During further observation, after administering the medications, LVN 2 placed the cups on top of the medication cart, used hand sanitizer, and proceeded to discard the used cups in the trash. LVN 2 went to the next resident's room, he touched the laptop on the medication cart, the next medication he was giving and went into the next resident's room. During an interview with LVN 2, on October 4, 2022, at 12:55 PM, LVN 2 was asked if he needed to perform hand hygiene prior to using the laptop and pouring medications for the next resident, LVN 2 stated, I did use hand sanitizer when I left out of Resident 8's room so that was my hand hygiene. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated March 2019, it indicated . 3. If hands are not visibly soiled, use a minimum 70% alcohol-based hand rub for all the following situations: . a. Before direct contact with residents, . d. Before preparing or handling medications, . g. After direct contact with residents . 2. During a review of Resident 21's admission Record, the admission Record indicated, Resident 21 was admitted to the facility on [DATE], with diagnoses which included sepsis (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), depression (disorder is used when symptoms cause significant distress or impairment in social, occupational), and dysphagia (disorder characterized by difficulty in swallowing). During a wound care treatment observation for Resident 21's wound care, by Licensed Vocational Nurse 3 (LVN 3) and the Infection Preventionist (IP), on October 6, 2022, at 2:16 PM, in Resident 21's room, LVN 3 removed the soiled dressing from Resident 21's right hand with scissors. LVN 3 did not sanitize the scissors after removing them from his pocket. After cutting the dressing off, LVN 3 placed the soiled dressings on the resident's bed. The IP entered the room and set up the wound supplies to be used. LVN 3 poured normal saline on the scissors and proceeded to provide wound care treatment. LVN 3 washed his hands with soap and water and left the soiled dressings on the bed. After handwashing, LVN 3 proceeded to pick up the soiled dressings with the paper towel he was using to dry his hands. During an interview with the IP, on October 6, 2022, at 2:50 PM, after wound care was completed, the IP confirmed LVN 3 should have placed the soiled dressings in the trash can and then removed them from the resident's room. During an interview and record review with the IP, on October 6, 2022, at 3:15 PM, 2022, the facility policy and procedure, titled, Wound Care, dated December 2014, was reviewed, which indicated It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 12 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is the policy for the facility to provide guidelines for the care of wounds to promote healing . 2. Use disposable cloth (paper towel is adequate) to establish clean barrier field. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached, 3. Wash and dry hands thoroughly. 4. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 5. Wash and dry hands thoroughly. 6. Put on exam glove. Loosen tape and remove dressing. 7. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. The IP stated the facility did not follow the policy. 3. A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), uterovaginal prolapse (occurs when pelvic floor muscles and ligaments stretch and weaken until they no longer provide enough support for the uterus), and urinary tract infection (infection in any part of the urinary system). A review of Resident 35's treatment administration record (TAR) indicated an order, dated August 30, 2022, for Resident 35's foley catheter and bag to be changed once a month, on the third of every month and as needed. During a concurrent observation and interview with Resident 35, on October 7, 2022, at 2:30 PM, Resident 35's foley catheter bag was inspected. There was no date or time written on the bag to indicate when it was last changed. Resident 35 stated she could not remember the last time her foley catheter or the bag was changed. During a concurrent observation and interview in Resident 35's room, with the LVN 3, on October 7, 2022, at 2:40 PM, LVN 3 inspected Resident 35's foley catheter bag and was unable to find any label on the bag. LVN 3 stated catheter bag should be dated. During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON), on October 7, 2022, at 2:45 PM, when asked if the facility's policy and procedure was to label the foley catheter drainage bag when it was changed, both responded, Yes. During record review of the facility's undated policy and procedure, titled, Urinary Catheter, the policy indicated . Section #4. Catheter Change, . 4.3 - Catheter and Urinary Bag change should labeled, dated, and documented in the Resident's record. Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Staff did not perform proper hand hygiene during medication pass for three residents (Residents 2, 248, 6, and 8). 2. Staff did not follow facility policy and procedure for wound care for Resident 21. 3. Resident 35's foley catheter bag (a bag connected to the catheter to collect urine) was not changed in accordance with facility policy and procedure. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 13 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 Findings: Level of Harm - Minimal harm or potential for actual harm 1.a. During a review of Resident 2's admission Record (clinical record with demographic information), the admission Record indicated, Resident 2 was admitted on [DATE], with the diagnoses of fracture of lower end of left femur (broken bone in the thigh), hypertension (high blood pressure), and myocardial infarction (heart not getting enough oxygen). Residents Affected - Some A medication administration observation for Resident 2 was conducted on October 5, 2022, at 10:42 AM. LVN 2 performed hand hygiene prior to medication preparation. Before administering Resident 2's medication, LVN 2 touched the laptop. LVN 2 did not perform hand hygiene prior to medication adminitration. During an interview, on October 5, 2022, at 10:45 AM, with LVN 2, when asked if hand hygiene was performed before giving Resident 2's medication, LVN 2 stated, No. LVN 2 further stated, I was supposed to sanitize my hands before I gave her [Resident 2] medication. 1.b. During a review of Resident 248's admission Record, the admission Record indicated, Resident 248 was admitted on [DATE], with the diagnoses of fracture of left femur, type 2 diabetes mellitus (high blood sugar levels), and hypertension. A medication administration observation for Resident 248 was conducted on October 5, 2022, at 10:59 AM. LVN 3 did not perform hand hygiene prior to medication preparation and administration. During an interview, on October 5, 2022, at 11:15 AM, with LVN 3, when asked if hand hygiene was performed before preparing and giving medication for Resident 248, LVN 3 stated, No, I did not do it. I should have cleaned my hands before preparing the medication and when giving it to the resident. 1.c. During a review of Resident 6's admission Record, the admission Record indicated, Resident 6 was admitted on [DATE], with the diagnoses of chronic kidney disease (long term loss of kidneys working), dementia (hard time remembering and/or making decisions), and hypertension. A medication administration observation for Resident 6 was conducted on October 5, 2022, at 11:15 AM. LVN 3 performed hand hygiene prior to medication preparation. Before administering medication to Resident 6, LVN 3 touched the laptop. LVN 2 did not perform hand hygiene prior to medication adminitration. During an interview on October 5, 2022, at 11:15 AM, with LVN 3, when asked if hand hygiene was performed before giving medication for Resident 6, LVN 3 stated, No, I did not do it. I should have cleaned my hands before giving the medication to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 14 of 15 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 055718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montclair Manor Care Center 5119 Bandera Street Montclair, CA 91763 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.unit of measurement) of livable space per resident for nine of 19 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. Findings: During an interview with the Administrator (Admin), on October 4, 2022, at 8:26 AM, the Admin stated the facility had nine of 19 resident rooms (Rooms 4, 5, 7, 8, 10, 11, 12, 14 and 16) which had less than the required square footage (80 sq. ft. of livable space). During an environmental tour with the Maintenance Supervisor (MS), on October 5, 2022, at 10:33 AM, nine of the 19 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: i. room [ROOM NUMBER] (3 beds) measured: 232.83 sq. ft. (77.6 sq. ft. per resident) ii. room [ROOM NUMBER] (3 beds) measured: 234.66 sq. ft. (78.2 sq. ft. per resident) iii. room [ROOM NUMBER] (3 beds) measured: 234.66 sq. ft. (78.2 sq. ft. per resident) iv. room [ROOM NUMBER] (3 beds) measured: 234.66 sq. ft. (78.2 sq. ft. per resident) v. room [ROOM NUMBER] (3 beds) measured: 231.07 sq. ft. (77 sq. ft. per resident) vi. room [ROOM NUMBER] (3 beds) measured: 234.66 sq. ft. (78.2 sq. ft. per resident) vii. room [ROOM NUMBER] (3 beds) measured: 233.72 sq. ft. (77.9 sq. ft. per resident) viii. room [ROOM NUMBER] (3 beds) measured: 231.95 sq. ft. (77.3 sq. ft. per resident) ix. room [ROOM NUMBER] (3 beds) measured: 231.95 sq. ft. (77.3 sq. ft. per resident) These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. During an interview with the Assistant Administrator (Admin 2), on October 7, 2022, at 2:05 PM, the Admin 2 confirmed the measurements for 19 of the 19 residents' rooms and nine of these did not meet the required 80 square feet per resident requirement. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055718 If continuation sheet Page 15 of 15