Health inspection·November 12, 2021

F 0552 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/11/2021 at 12:36 pm, Director of Nursing (DON) stated, it was important to obtain an informed consent for the use of psychotropic medication from the resident or responsible party because they have the right to be involved in the care and since medication might cause an adverse effect to the resident. DON also stated consent was not valid if it was not signed and dated as indicated in the facility's policy and procedure. Residents Affected - Few A review of the undated Policy and Procedure (P&P) titled, Informed Consent, indicated that the facility staff is responsible to verify that the physician has obtained consent. P&P also indicated that the facility is responsible to assure that consent was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 2 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Some 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 assess and provide the necessary services and interventions for two of three residents (Resident 20 and 53) with an indwelling urinary catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) as indicated in the facility policy. a. For Resident 20, the facility failed to assess and provide interventions for the presence of sediments in the resident's indwelling urinary catheter tubing. b. For Resident 53, the facility failed to ensure the urinary catheter tube was not touching the floor. These deficient practices had the potential for the residents to develop urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]). Findings: a. A review of the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included spinal stenosis (narrowing of the spaces within your spine which can put pressure on the nerves that run through it), quadriplegia (paralysis [loss of voluntary movement] of all four arms and legs), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). A review of Resident 20's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/31/2021, indicated Resident 20 does not have the cognitive skills (ability to perceive and react, process and understand, store and retrieve information, make decisions and produce appropriate responses) for daily decision making. The MDS indicated Resident 20 was totally dependent on staff for bed mobility, transfer, managing urinary catheter and personal hygiene. The MDS indicated Resident 20 has an indwelling catheter in place. A review of Resident 20's physician order, dated 8/26/2021, indicated to change Foley catheter French (Fr) 16/10 cubic centimeters (cc) and bag as needed if leaking, plugged or pulled out, obstruction, excessive sedimentation or when the closed system is compromised. During an observation on 11/9/2021 at 9:13 am in Resident 20's room, Resident 20's catheter tube was hanging on the side of the bed. Resident 20's catheter tubing was noted with urine, yellow in color with sediments. During an observation on 11/10/2021 at 8:46 am in Resident 20's room, Resident 20's indwelling urinary catheter tube with sediments. During a concurrent observation and interview on 11/10/2021 at 1:01 pm with Licensed Vocational Nurse 1 (LVN 1) in Resident 20's room, LVN 1 stated Resident 20's indwelling urinary catheter tube had sediments. LVN 1 stated complications from failure to address the sediment in the indwelling urinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 3 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 catheter tubing can lead to a UTI. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/10/2021 at 3:39 pm with Registered Nurse Supervisor 1 (RN 1), RN 1 stated to monitor urine for cloudiness, hematuria (blood in the urine), and presence of sediments every shift when caring for a resident with an indwelling urinary catheter. RN 1 stated frequent checks are important to prevent an episode of UTI. Residents Affected - Some A review of Resident 20's care plan titled, Alteration in Bowel and Bladder System Related to Urinary/Bowel Incontinence, dated 8/25/2021, indicated interventions included were to check Resident 20 at least every two hours, provide incontinent care, observe for signs and symptoms (s/s) of UTI such as foul smelling urine, hematuria, and to refer to MD accordingly. During a review of the facility's policy and procedure (P&P) titled, Urinary Catheter Care, revised September 2014, indicated the purpose of the procedure was to prevent catheter-associated urinary tract infections. The P&P indicated to observe the resident for complications associated with urinary catheters, check the urine for unusual appearance (i.e. color, blood, etc.), observe for other signs and symptoms of urinary tract infection or urinary retention and to report findings to the physician or supervisor immediately. P&P also indicated the following information should be recorded in the resident's medical record: 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. b. A review of the admission Record indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included benign prostatic hyperplasia ( BPH, a condition in which an overgrowth prostate tissue pushes against the urethra and the bladder, blocking the flow of the urine), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 53's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/22/2021, indicated cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS also indicated Resident 53 required total dependence from staff for transfer, toilet use and personal hygiene. During a concurrent observation in Resident 53's room and interview with Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) on 11/9/2021 at 9:43 am, Resident 53's foley catheter (FC) tubing was touching the floor. IPN stated, FC tubing should not be touching the floor because the floor was dirty. IPN stated, it was important that the FC tubing should not be touching the floor because it might introduce the bacteria to the resident. During an interview on 11/10/2021 at 9:11 am, the Director of Nursing (DON) stated FC tubing should not be touching the floor to prevent any kind of infection. A review of the Policy and Procedure (P&P) titled, Urinary Catheter Care, dated 9/2014, P&P indicated to be sure the catheter tubing and drainage are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 4 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to assess and document for one of three sampled residents (Resident 56) receiving hemodialysis (a process of removing toxins and excess fluid in the blood using a machine) on 10/27/2021, 10/29/2021, 11/3/2021 and 11/5/2021 on the Dialysis Communication Record included: Residents Affected - Few a. vital signs (measurement of the blood pressure, heart rate, respiratory rate, temperature) b. mental status and pain c. dialysis access site pain, redness, swelling, bleeding, presence of bruit (an audible vascular sound associated with turbulent blood flow) and thrill (vibration felt with the finger to indicate blood flowing through your dialysis site) This deficient practice had the potential to result in infection, bleeding and pain that is not identified timely which could result in delayed care and interventions and a decline in the resident's well-being. Findings: A review of the admission Record indicated Resident 56 was admitted to the facility with diagnoses that included end stage renal disease (ESRD), failure of the kidney to filter out extra fluids and toxins from the body. A review of the MDS (Minimum Data Set, a resident assessment and care screening tool), dated 10/29/2021, indicated Resident 56 had no cognitive (ability to think and reason) impairment and required extensive assistance with one-person physical assist on transfer, toilet use and personal hygiene. A review of the physician order, dated 10/22/21, indicated Resident 56 was to receive hemodialysis Monday, Wednesday, and Friday at 2pm. During a concurrent record review of Resident 56's Dialysis Communication Record (DCR) and interview with Registered Nurse Supervisor (RN 1) on 11/10/21 at 2:23 pm, RN1 stated Resident 56's DCR did not indicate Resident 56 was assessed prior to going to the hemodialysis center (a place outside of the facility where residents received hemodialysis) : 1. On 10/27/21, there was no documented evidence Resident 56 was assessed for cognitive status, vital signs, catheter site condition such as redness, swelling, drainage or pain prior to going to the hemodialysis center. 2 On 10/29/21, there was no documented evidence Resident 56 was assessed for cognitive status, catheter site condition such as redness, swelling, drainage or pain, and presence of bruit and thrill prior to going to the hemodialysis center. 3. On 11/3/21, there was no documented evidence Resident 56 was assessed for vital signs, cognitive status, catheter site condition such as redness, swelling, drainage or pain, prior to going to the hemodialysis center (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 5 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4. On 11/5/21, there was no documented evidence Resident 56 was assessed for vital signs, cognitive status, catheter site condition such as redness, swelling, drainage or pain, and presence of bruit and thrill prior to going to the hemodialysis center. During an interview with RN 1 on 11/10/21 at 2:23 pm, RN 1 stated, Resident 56 should had been assessed for vital signs, condition of the catheter site and any change of condition prior to and after the hemodialysis. RN 1 stated the assessment should be documented in the Dialysis Communication Record so that the staff in the dialysis center could determine if the hemodialysis should be done or not. A review of the plan of care for Resident 56, revised on 11/5/2021, indicated to monitor and document for signs and symptoms of infection such as redness, swelling and bleeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 6 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure one of one Infection Preventionist Nurse (IPN, in charge of infection control) had the competency and skill set to identify and address residents with symptoms of respiratory infection (cough, runny nose, fever). This failure had the potential to the spread respiratory infection associated with Coronavirus 19 (COVID-19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing), influenza, and pneumonia to already vulnerable residents leading to complications related to the virus, including hospitalization and death. Findings: During an observation on 11/9/2021, at 9:42 am, Resident 24's was overheard coughing outside from the hallway. The door to Resident 24's room was open and there was no curtain barrier between Resident 24 and her roommate, Resident 42. Resident 24 was in her wheelchair inside her room with a wet cough and coughing uncontrollably. There was no signage posted indicating these residents were in quarantine. During an observation on 11/9/2021, at 10:28 am, Resident 36 was overheard coughing from the hallway. The door to Resident 36's room was open and there was no signage posted indicating these residents were in quarantine. Resident 36 had a wet cough. During an interview on 11/9/2021, at 11:57 am, IPN stated the residents who were identified with a cough were not isolated from other asymptomatic residents because the identified residents' rapid antigen tests for Covid-19 came out negative. IPN stated residents with coughing symptoms were not isolated. IPN stated, If everyone coughs here, do you want me to isolate them? During an interview on 11/9/2021, at 12:34 pm, IPN stated residents with cough were tested for COVID-19 using the Rapid Antigen test. IPN stated that the coughing residents were not tested for influenza or pneumonia. IPN further stated x-rays were done for the residents. During an interview on 11/10/2021 at 4:30 pm, IPN stated Resident 47 was transferred to the hospital for shortness of breath and was diagnosed with pneumonia. IPN stated pneumonia was not a condition that requires isolation, even though the resident has signs and symptoms of respiratory disease such as coughing. IPN further stated staff use standard precautions for all residents, which is gloves and mask. During an interview on 11/10/2021 at 6:03 pm, Administrator (ADM) stated everyone who is symptomatic should be in isolation (quarantine). During an interview on 11/10/2021, at 6:09 pm, IPN stated coughing is a symptom of COVID-19. IPN stated he tested all residents who were symptomatic with a Covid-19 rapid antigen test so facility would know who to quarantine. IPN stated facility staff were not gowning when providing care to residents who were coughing because residents were not in isolation. During an interview on 11/10/2021, at 6:11 pm, ADM stated residents with cough should be isolated, quarantined for 10 days and the whole facility would be in a yellow zone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 7 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's LTC Respiratory Surveillance Line List, dated 11/9/2021, the line list indicated Resident 24's onset of cough was identified on 11/7/2021, Resident 36's onset of cough was identified on 11/7/2021, and Resident 29's onset of cough was identified on 11/8/2021. Influenza tests were performed two days later, on 11/9/2021, for Residents 24, 29, and 36. A review of the Facility's undated Infection Preventionist (IP) Job Description, indicated essential duties and responsibilities of the IPN included 1) oversee the operations of the infection prevention, epidemiology and relevant safety programs and 2) leads facility hygiene program to anticipate, recognize, evaluate, mitigate and control workplace conditions related to infection control and prevention. A review of the Department of Public Health, Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, dated 10/21/2021, indicated every staff member or resident with symptoms of COVID-19 (fever, cough, dyspnea, new loss of taste or smell, chills/rigors, myalgias, rhinorrhea, vomiting or diarrhea, sore throat, fatigue, headache, and confusion) should be tested as soon as possible, regardless of vaccination status. The guideline indicated all symptomatic residents should be presumed infectious pending test results and should be in quarantine in a private room in the Yellow Cohort (mixed quarantine and symptomatic residents), if possible. The guideline also indicated during the influenza season, residents with acute respiratory symptoms should also be tested for influenza. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/#cohorting A review of Interim Guideline for COVID-19 Antigen Testing in Skilled Nursing facilities, dated 10/20/2020, indicated symptomatic residents tested for point of care Antigen test with negative results should be confirmed with COVID-19 Polymerase Chain Reaction (PCR) test. The guideline also indicated residents be quarantined in the Yellow Cohort pending PCR confirmation and when PCR results are confirmed negative, residents can be moved to the [NAME] cohort with droplet precautions until after the resident is clinically improved and 24 hours after resolution of fever. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/antigen/ FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 8 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information posted reflected the actual hours worked and the total number of staff on 11/9/2021 and 11/10/2021 was accurate. Residents Affected - Some This deficient practice had the potential to result in misinformation to the residents and the public of the facility's nursing staffing data. Findings: During an observation on 11/9/2021 at 11:53 am, a daily nurse staffing information was posted by the nursing station three. During a concurrent record review and interview on 11/10/2021, at 2:53 am with Director of Staff Development (DSD), the nurse staffing information and the actual staffing sign in sheet for the staff reflected the following: 1. On 11/09/2021 for the 7 am to 3 pm shift, there were four Licensed Vocational Nurse (LVN (unidentified) on the nursing staffing posting while the sign in sheet reflected three LVNs (unidentified). 2. On 11/09/2021 for the 11 pm to 7am shift, there were no Certified Nursing Assistants CNAs listed on the nursing staffing posting while the sign in sheet reflected four CNAs (unidentified). 3. On 11/10/2021 for the 7 am to 3 pm shift, there were four LVNs on the nursing staffing posting while the sign in sheet reflected three LVNs (unidentified). During an interview, on 11/10/2021 at 2:59 am, DSD, stated the daily staff posting on 11/09/2021, 11/10/2021 must be correct and updated for the visitors and family members to know exactly how many employees provided care to the residents. During an interview, on 11/11/2021 at 12:35 am, the Director of Nursing (DON), stated daily staffing posting must be updated and current for the visitors and staff to know how many nurses were working on that day. DON stated for the residents to know if they were getting enough care. A review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised date 07/2016, P&P indicated that within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location and in a clear readable format. The information recorded on the form shall include total number of licensed and non licensed staff working for the posted shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 9 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the failed to report the pharmacist's recommendations regarding the drug regimen review (is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for three of 19 sampled residents (Residents 59, 44 and 29) to the residents' attending physician, the facility's medical director, and Director of Nursing (DON). a. For Resident 59, the facility failed to address the pharmacist's recommendation to administer Tamsulosin (used to treat enlarged prostate) at hour of sleep (HS at night) or at dinner to avoid postural hypotension (drop of blood pressure from sudden change of position from lying to siting). b. For Resident 44, the facility failed to address the pharmacist's recommendation to rotate and document the injection site for Lovenox (medication use as blood thinner) and stop date or term of therapy and specify the type of pain that required the pain medication for the month of October 2021. c. For Resident 29, the facility failed to address the pharmacist's recommendation to administer Prednisone (medication used to reduce inflammation) with food or snack. Findings: a. A review of Resident 59's admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included, sepsis (a severe life-threatening infection in the blood) and unspecified hypotension (low blood pressure). A review of Resident 59's physician order dated 7/30/2021, indicated to administer Tamsulosin HCL (Hydrochloride) capsule 0.4 milligrams (mg, a unit of measurment) by mouth one time a day for benign prostate hyperplasia, (BPH an enlargement of the prostate). A review of Resident 59's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 8/5/2021, indicated Resident 59 was sometimes able to understand others and able to express her ideas and wants. A review of the Consultant Pharmacist Medication Review, dated 8/1/2021 to 8/19/2021, indicated the pharmacist (unidentified) recommended to administer Resident 59 Tamsulosin at HS or at dinner to avoid postural hypotension. During an interview and record on 11/12/2021 at 10:50 am, DON stated she did not review the pharmacist's recommendations on August 2021 to ensure the resident received Flomax at HS to prevent postural hypotension. b. A review of Resident 44's admission Record dated on 11/9/2021, indicated the facility admitted Resident 44 on 7/5/2021 with diagnoses of congestive heart failure (condition where the heart cannot pump enough blood to meet the body's needs), asthma (condition in which the airways narrow and swell and may produce extra mucus), and diabetes (chronic (long-lasting) health condition that affects how your body turns food into energy). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 10 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 44's MDS dated [DATE] indicated Resident 44 was cognitively intact in memory and cognition (ability to think and reason), and required extensive assistance with one person assist with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 44's Consultant Pharmacists Medication Regimen Review for Resident 44, dated 8/19/2021, indicated to update Lovenox (Enoxaparin) order to read rotate injection site, and to add a stop date or term of therapy. A review of the Consultant Pharmacist's Medication Regimen Review for Resident 44, dated 10/26/2021, indicated to specify type of severe pain that is requiring routine use of Methadone (a pain medication) do not use pain management as diagnosis. A review of Resident 44's Physician Order Summary Report, dated 10/30/2021, indicated to administer Enoxaparin Sodium Solution 40 milligrams (mg)/ 0.4 milliliters (mL) subcutaneously (under the skin) one time a day for deep vein thrombosis (DVT, blood clot) prophylaxis (prevention) rotate injection site with start date of 9/16/2021. The physician order did not indicate the stop date or term of therapy. A review of Resident 44's Medication Administration Record (MAR), for the month of November 2021, did not indicate the injection site of Enoxaparin Sodium subcutaneously to determine if the injection site was rotated. A review of Resident 44's MAR for the month of November 2021, indicated Methadone Hydrochloride (medication to relieve pain) tablet 5 mg, give one tablet by mouth every 8 hours for pain management severe (7-10). The MAR indicated Resident 44 continued to receive Methadone without indication of what type of severe pain the resident had that required the administration of Methadone. During an interview on 11/11/2021 at 3:50 pm, the Director of Nursing (DON) stated it was important to review the Medication Regimen Review (MRR) every month so changes could be addressed for any medications related to possible interactions, adverse effects, doses that could not be appropriate, and labs that needed to be checked for certain medications. During an interview on 11/12/2021 at 10:47 am, the DON stated she reviewed the MRR with the pharmacist but missed August 2021 because the facility's resident pharmacist was on paternity leave and the MRR was performed off-site by another pharmacist. The DON stated that MMR recommendations should be acted upon within five days of receipt. A review of the Facility's Medication Regimen Review (Monthly Review) Policy and Procedure, revised August 2014, indicated pharmacy recommendations were acted upon and documented by the facility staff and or the prescriber. The policy indicated the Physician accepted and acted upon suggestion or rejected and provided an explanation for disagreeing. The policy indicated the DON or designated licensed nurse addressed and documented recommendations that did not require a physician intervention such as monitor blood pressure. c. A review of Resident 29's admission Record dated on 11/9/2021, indicated the facility admitted Resident 29 on 9/12/2021 with diagnoses of myasthenia gravis (autoimmune disorder resulting in weakness in arm and leg muscles, double vision, and difficulties with speech and chewing), cellulitis (bacterial skin infection) of the left upper limb, type 2 diabetes (body unable to maintain blood sugar at normal levels). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 11 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 29's MDS dated [DATE], indicated Resident 29 was cognitively intact in memory and cognition (ability to think and reason). Resident 29 was extensive assistance with one person assist with bed mobility and personal hygiene, and two-person assist with transfer, dressing, and toilet use. Resident's 29 MDS indicated that Resident 44 was frequently incontinent of bowel movements. A review of Resident 29's Medication Administration Record (MAR) for the month of November 2021, indicated Resident 29 received Prednisone 20 mg (two tablets) one time a day daily without food or with a snack as recommended by the pharmacist. A review of Resident 29's Consultant Pharmacist's Medication Regimen Review dated 10/26/2021, indicated to comply with CMS (Center for Medicare and Medicaid services) guidelines regarding the administration of prednisone and update the order to read with food or with snack. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 12 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, and record review, the facility failed to address the indication for the use of antipsychotic medication (are a group of medicines that are mainly used to treat mental health illnesses) for one of one sampled resident (Resident 15). Resident 15 received Zoloft (Sertraline HCL, antipsychotic medication) and Quetiapine Fumarate (Seroquel, antipsychotic medication) without a psychiatric evaluation. This deficient practice had the potential for Resident 15 to experience adverse reaction (undesired harmful effect) or side effects (undesired effect) to the medications that could lead to a decline in the resident's quality of life and wellbeing. Findings: A review of Resident 15's admission Record indicated the facility admitted Resident 15 on 8/22/2021 with diagnoses of history of falling, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) in other diseases classified elsewhere without behavioral disturbance, unspecified psychosis (an impaired relationship with reality) not due to a substance or known physiological condition, anxiety (a feeling of worry, nervousness, or unease) disorder, Alzheimer's disease (a disease of the brain that results in the gradual loss of memory, speech, movement, and the ability to think clearly), and auditory hallucinations (hearing noises without an external stimulus). A review of Resident 15's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/28/2021, indicated Resident 15 did not have the cognitive skills (ability to perceive and react, process and understand, store and retrieve information, make decisions and produce appropriate responses) for decision making. The MDS Section E - Behavior indicated Resident 15 did not exhibit potential indicators of psychosis and Resident 15 did not exhibit any behavioral symptoms such as hitting, kicking, screaming at others, or verbal/vocal symptoms like screaming directed towards others or not directed towards others. The MDS indicated Resident 15 did not exhibit any behavior rejecting the evaluation of care necessary to achieve the resident's goals for health and well-being. The MDS indicated Resident 15 required extensive assistance with dressing, eating, toilet use, and personal hygiene. A review of Resident 15's Medication Administration Record (MAR), dated August 2021, indicated Resident 15 received Zoloft (Sertraline HCL) Tablet 50 milligrams (mg, a unit of measurement) by mouth one time a day for Anti-Depressant ordered on 8/22/2021 at 4:58 pm and Quetiapine Fumarate (Seroquel) Tablet 25 mg by mouth two times a day for Anti-Psychotic ordered on 8/22/2021 at 4:58 pm. The MAR for September 2021, October 2021 and November 2021 indicated Resident 15 received Seroquel and Zoloft since admission. During an interview on 11/10/2021 at 1:27 pm Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 15 was forgetful and has observed the resident talking to someone who was not there. CNA 2 stated resident was a happy resident but would get sad when the resident talked about her son. During a concurrent interview and record review on 11/12/2021 at 2:49 pm Licensed Vocational Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 13 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 (LVN) stated when a resident was admitted with an antipsychotic medication, an order for a psychiatric evaluation was obtained and the doctor verified the order and obtained an informed consent for the medication. In review of Resident 15's medical chart, LVN 1 was unable to find the psychiatric evaluation for Resident 15. LVN 1 stated the psychiatric evaluation report should be in the chart but if was not, it probably was not done. LVN 1 stated she observed Resident 15 talking to herself when no one was there. LVN 1 stated when Resident 15 was admitted to the facility. During an interview on 11/12/2021 at 3:01 pm the Director of Nursing (DON), stated upon admission of a resident, nurses would verify the order of the antipsychotic medication with the attending physician, the attending physician obtained an informed consent from the resident if the resident could consent for themselves or if they could not, it was obtained from the resident's responsible party. The DON stated the Interdisciplinary Team (IDT) would conduct a care plan meeting with resident's responsible party and discuss current medication use and if needed, make a referral to psychiatrist for a psychiatric evaluation if the IDT decided one was needed. During an interview on 11/12/2021 at 4:14 pm DON stated a psychiatric evaluation must be performed before starting Zoloft for Resident 15. DON stated a new resident had a psychiatric evaluation before starting any antipsychotic medication. DON stated a psychiatric evaluation for the antidepressant and antipsychotic for Resident 15 was not done. A review of the facility's policy and procedure titled, Antipsychotic Medication Use, dated Revised December 2016, indicated Policy Statement - Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Under Policy Interpretation and Implementation - 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use, 8. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) The behavioral symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency, 10. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: c. not sufficiently relieved by non-pharmacological interventions, d. not due to environmental stressors (e.g., alteration in the resident's customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; and e. not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 14 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 food items were stored under sanitary conditions as indicated on the facility policy by failing to: Residents Affected - Some a. Ensure not to store a dented food can in the pantry. b. Ensure food items were dated once opened. c. Ensure there was no food contamination coming from the debris of the cracked ceiling above the steam table. These deficient practices had the potential for food contamination and for the residents to be at risk for contracting food borne illnesses. Findings: a. During an initial tour observation of the kitchen and on 11/9/2021 at 8:55 am, together with the Dietary Supervisor (DS), observed there was a 289 kilogram (kg, unit of weight) enchilada sauce dented can stored with other non-dented cans on the rack. DS stated the product was damaged and should not be there. A review of the Policy and Procedure (P&P), titled, Food Storage, revised on 2017, P&P indicated all opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area. b.During an observation on 11/09/2021 at 8:59 am, together with the DS, observed lime gelatin inside a ziplock bag and was not dated. DS stated food items should be dated the first time it would be opened. During an observation on 11/12/2021 at 12:04 pm, together with the DS, observed several spices including whole thyme, seasoning salt, and imitation vanilla flavor were not dated to indicate when the spices were opened. DS stated she did not check if it was labeled when the date was opened. A review of the P&P, titled, Receiving, revised on 2017, P&P indicated food and supplies would be received according to facility approved standards and practices to ensure quality of products received. The policy indicated unacceptable products (dented cans) would be rejected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 15 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the Quality Assurance Committee (QA is the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards) developed and implemented appropriate plan of action to identify and adress residents with symptoms of respiratory infection such as stuffy nose (congestion), headache, new and increased cough for 13 of 13 sampled residents (Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) by failing to: a. Immediately isolate or quarantine (separate someone exposed to infectious and contagious disease) Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209 to the Yellow Zone (an area in the facility in which residents with symptoms of Coronavirus-19 [COVID-19, a respiratory illness that can spread from person to person] or respiratory infection or had contact with someone with respiratory infection were placed). b. Ensure the staff wore appropriate personal protective equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness) such as gown and N95 (respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask when providing care to residents with respiratory infections. b. Ensure the residents were tested for Influenza Virus (highly contagious, easily transmitted respiratory infection) during the Influenza season. c. Develop a line listing (a table in which important information is recorded on each person during an outbreak [sudden rise in the incidence of a disease]) of residents to determine the number of residents affected and what area of the facility the residents resided that was the most affected. d. Provide other diagnostic tests to determine the probable source or cause of the respiratory infections. e. Investigate the probable cause respiratory infection and determine if there was a non-compliance with the infection control practices in the facility. These deficient practices lead to an Influenza Virus outbreak in the facility for Residents 18, 24, 36 and 46, infected with Influenza Virus RSV (respiratory syncytial virus) and one resident (Resident 209) infected with Influenza A and B, and had the potential to spread the infection to residents, staff, and visitors. Cross Reference to F880 Findings: During a facility tour on 11/9/2021 and on 11/10/21, the residents (unidentified) were observed with cough and were not isolated or quarantined, the facility staff did not wear PPE such as gown and N95 mask when providing close care for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 16 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an entrance conference on 11/9/2021 at 8:45 am conducted with the Administrator (ADM) and the Infection Preventionist Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated Resident 56 was transferred to the hospital on [DATE] due to cough and tested negative of COVID 19 rapid test (antigen test). The IPN stated on 11/6/2021 and 11/7/2021, Residents 5,6,7,15 and 24 were observed coughing. The IPN stated today (11/9/21) four (4) more residents were observed coughing and all nine residents tested negative of COVID 19. During an interview on 11/9/2021 at 12:30 pm the Director of Nursing (DON) stated the residents (unidentified) observed with new onset cough were not tested for Influenza Virus.The DON stated the residents should had been tested for Influenza Virus during the Flu season as indicated in the facility's policy and procedure. During an interview on 11/9/2021, at 11:57 am, the IPN was asked if the identified nine residents with cough were quarantined or isolated until the cause of the resident's cough were determined. The IPN replied If everyone coughs here, do you want me to isolate them? The IPN explained all the residents with cough were not quarantined or isolated and remained in the [NAME] Zone (an area in the facility where residents without contact with or signs and symptoms of respiratory infection are located) because of negative COVID 19 test. During an interview on 11/9/2021 at 12:16 pm, the IPN and the DON stated there was no line listing or surveillance listed documented because there was no outbreak that was identified. During an interview on 11/10/2021 at 11:47 am, the IPN was asked if there were other tests besides COVID 19 that were conducted to determine the cause of residents' cough or identify other possible respiratory infection such as Influenza or pneumonia (lung inflammation caused by bacterial or viral infection). The IPN stated Residents 5, 7, 15, 20, 24, 29, 36, 47, 54, and 56 were not tested for pneumonia and Influenza infection because most of the residents with cough received pneumonia and influenza and COVID 19 vaccines. A review of the letter from the Department of Public Health Nurse (PHN), dated 9/2/2021, indicated the facility had been cleared to reopen for admissions and transfers. The letter indicated the PHN recommended all individuals continue to enforce respiratory etiquette and strict hand washing for the staff, residents, and visitors. During an interview related to the QAPI with the ADM and the DON on 11/12/2021 at 11:16 am stated the facility recently had an outbreak of COVID 19 that closed on 9/2/21. The ADM stated the residents identified with cough were not viewed as a possible respiratory outbreak but rather a common cold, because the residents tested negative for COVID 19 and the other possible cause of respiratory was not investigated. During an interview on 11/12/2021 at 11:21 am, the DON stated the facility should have identified the residents with signs and symptoms of cough and respiratory infection as a possible infection outbreak and the Infection Control Committee should had implemented interventions to mitigate the possible spread of the infection. A review of the facility's 2021 QAPI Plan, indicated the purpose of the facility's QAPI was to take a proactive approach to continually improve the way the facility care for and engage with the residents, caregivers, and other partners so the facility could realize its vision to provide the highest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 17 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0867 Quality of Care, the organization used quality assurance(QAA) and performance improvement to make decisions and guide the faciltiy's day-to-day operations. 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: 055817 If continuation sheet Page 18 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement interventions to prevent and control the spread of respiratory diseases such as Coronavirus 19 (COVID-19, a severe respiratory illness caused by virus and spread from person to person) and Influenza virus (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) for 13 of 13 sampled residents (Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) by failing to: Residents Affected - Some a. Quarantine (separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick) Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) who had symptoms of cough into a Yellow Zone (an area in the facility where residents suspected, had contact with or with symptoms of respiratory infection were confined). b. Ensure staff (in general) who had close resident contact with Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) donned (put on) full protective personal equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness). c. Test Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209 for COVID-19 and for Influenza virus. d. Ensure staff perform hand hygiene after contact with the residents and equipment. These deficient practices had the potential to spread COVID-19 and or influenza virus to residents, staff, and visitors that could lead to severe respiratory illness, hospitalization, and/or death. On 11/10/2021 at 7:39 pm, the Department of Public Health (DPH) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) with regards to the facility's failure to implement infection control practices according to the local DPH guidelines and the facility's policies and procedures for infection control in the presence of the facility's Director of Nursing (DON), the Administrator (ADM) and the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment). On 11/11/2020 at 4:44 pm, while onsite and after confirming the facility's implementation of the immediate corrective actions, DPH accepted the Plan of Action (POA, interventions to correct the deficient practices) and removed the IJ in the presence of the DON and ADM. The acceptable POA was as follows: 1. On 11/10/2021, the facility placed all residents into quarantine in the facility's Yellow Zone. 2. On 11/10/2021, the facility tested all residents in the facility. 3. On 11/10/2021 and on 11/11/2021, the facility tested all staff for COVID-19. 4. The facility completed testing all the residents in the facility for influenza on 11/10/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 19 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Immediate jeopardy to resident health or safety 5. On 11/10/2021, all staff was provided with proper PPE and provided in-services on proper PPE use and hand hygiene. 6. On 11/10/2021, the facility placed additional signages for donning (put on) and doffing (remove) PPEs and had isolation carts (store and organize all the supplies required to mitigate the risk of transmitting infection) in front of every residents' rooms. Residents Affected - Some 7. On 11/11/2021 the facility's Infection Prevention/DSD Consultant provided an in-service education to the facility's IPN regarding the DPH, CDC, and California Department of Public Health (CDPH) infection control guidelines regarding residents with respiratory infection symptoms such as cough. Findings: A review of the facility's untimed Long Term Care Surveillance Line List for Respiratory Infection (a table that summarizes information about person(s) who may be associated with an outbreak), dated 11/9/2021, indicated Residents 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, and 56 had symptoms of cough. The Line List indicated Resident 56's cough symptoms started on 10/29/2021, Resident 15 and Resident 5's cough symptoms started on 11/6/2021, Resident 24, 7, and 36's cough symptoms started on 11/7/2021, Resident 47, 29, 20, 54's symptoms of cough started on 11/8/2021, Resident 18's symptoms of cough started on 11/9/2021, and Resident 46's symptoms of cough started on 11/10/2021. A review of the LTC Surveillance Line List for Respiratory Infection, dated 11/11/2021 provided by the IPN indicated one additional resident, Resident 209 had symptoms of cough. During an entrance conference interview on 11/9/2021 at 8:45 am, the IPN stated Residents 5, 7, 15, 18, 20, 24, 29, 46, 47, and 54 had symptoms of cough and were not quarantined or isolated and remained in the facility's [NAME] Zone (an area in the facility where residents without symptoms of respiratory infection such as cough were placed) with other residents who did not have any respiratory symptoms. The IPN stated the facility transferred Resident 56 to a general acute care hospital (GACH) on 11/5/2021 due to cough. A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included CVA and renal insufficiency (failure of the kidney to filter out extra fluid and toxins in the blood). A review of Resident 18's MDS dated [DATE], indicated Resident 18 had no impairment in memory and cognition, and required extensive assistance with one person on activity of daily living. During an observation and interview on 11/10/2021 at 12:48 pm, Resident 18 was observed coughing while sitting on a wheelchair at the doorway of his room in the facility's [NAME] Zone. Resident 18 stated he started feeling congested and began coughing on 11/9/2021. A review of Resident 24's admission Record indicated the resident was readmitted on [DATE] with diagnoses that included chronic ischemic heart disease (chest pain or discomfort that occurs when blood flow to heart is reduced, preventing heart from receiving enough oxygen). A review of Resident 24's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 9/1/2021 indicated Resident 24 had severely impaired memory and cognition (ability to think and reason), and required extensive assistance with one person on activity of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 20 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Immediate jeopardy to resident health or safety During an observation on 11/9/2021, at 9:42 am, in the facility's [NAME] Zone, no PPE or signage, Resident 24 was inside her room sitting in a wheelchair and repeatedly coughing. The curtain between Resident 24 and her roommate Resident 42, was opened. During an interview on 11/9/2021, at 9:44 am, Certified Nursing Assistant 3 (CNA 3) stated Resident 24 was coughing all night on 11/8/2021. Residents Affected - Some During an interview on 11/9/2021, at 9:49 am, Resident 42 was awake stated she told the DON (unidentified date and time) about Resident 24 coughing. Resident 42 stated she was concerned because she has asthma (a condition that cause the lungs inflammation that cause difficulty breathing) and stated Resident 24's cough got worse over the weekend (11/6/2021 to 11/7/2021). During an observation and interview on 11/10/2021 at 11:30 am, Resident 24 was observed sitting in a wheelchair going back to her room in the hallway (Green Zone) and was coughing productively (mucus). Resident 24 stated she returned to her room from the rehabilitation room (exercise treatment room) because she was coughing too much. Resident 24 stated she had been coughing a lot, since 11/7/2021. During an interview with on 11/10/2021 at 12:45 pm, the IPN stated the residents (unidentified) with new or worsened cough were not tested for Pneumonia (lung inflammation caused by bacterial or viral infection) and or Influenza infection because most of the residents (unidentified) with cough received pneumonia, influenza and COVID-19 vaccines. A review of Resident 29's admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included myasthenia gravis (autoimmune disorder resulting in weakness in arm and leg muscles, double vision, and difficulties with speech and chewing). A review of Resident 29's MDS dated [DATE], indicated Resident 29 was cognitively intact in memory and cognition and required extensive with activities of daily living. During an observation and interview on 11/10/2021 at 8:44 am, inside Resident 29's room, in the facility's [NAME] Zone without PPE signage, Resident 29 was awake coughing lying in bed under the covers. Resident 29 stated he was trying to cough the phlegm, (thick mucus) out. Resident 29's door was opened, and Resident 29 was coughing. During a telephone interview on 11/10/2021 at 4:48 pm during a telephone interview with the Public Health Nurse (PHN) stated she provided the IPN via email a list of reportable conditions. The PHN stated the IPN informed her that there were residents (unidentified) with cough. The PHN stated she did not inform the IPN not to isolate the residents with cough because she could not make any comments or suggestions because she was not present in the facility. During an interview on 11/10/2021 at 6:05 pm, the IPN stated not all residents (unidentified) with symptoms of cough were tested for COVID-19. The IPN stated he was aware of the DPH infection control guidance to isolate or quarantine the residents with cough and aware respiratory virus could spread through droplets. During an interview on 11/10/2021, at 6:11 pm, the ADM stated there was confusion with taking care of residents who had a cough. ADM stated the residents with cough should be isolated, quarantined away from residents who did not have symptoms and the whole facility should be in a yellow zone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 21 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Immediate jeopardy to resident health or safety Residents Affected - Some A review of Resident 36's admission Record indicated the facility admitted Resident 36 on 9/22/2021 with diagnoses of heart failure (condition where the heart cannot pump enough blood to meet the body's needs) and chronic obstructive pulmonary disease (COPD, a condition in which lung airways narrow and cause difficulty or discomfort in breathing). A review of Resident 36's MDS, dated [DATE], indicated Resident 36 had no cognitive and memory impairment, that required extensive assistance with activities of daily living. During an observation and interview on 11/9/2021, at 10:28 am, Resident 36 was observed touching his chest while coughing in the hallway in the facility's [NAME] Zone. Resident 36 stated his cough made it harder for him to breathe. During an interview on 11/9/2021, at 11:57 am, the IPN stated the residents (unidentified) who had cough were not isolated from other residents without cough. The IPN stated cough was a sign and symptom of respiratory infection such as COVID 19 and influenza. A review of Resident 42's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included asthma. A review of Resident 42's MDS, dated [DATE] indicated Resident 42 was able to express her ideas and wants and had no impaired memory and cognition. A review of the admission Record, Resident 46 was admitted to the facility on [DATE], with diagnosis of cerebrovascular accident (CVA, or stroke a blockage of blood flow to the brain). A review of the MDS, dated [DATE], indicated Resident 46 had severely impaired memory and cognition (ability to think and reason) and required total assistance with one person assistance on activities of daily living. During a medication administration observation on 11/10/2021 at 9:05 am, inside Resident 46's room, Licensed Vocational Nurse 4 (LVN 4) was not wearing an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and not wearing a gown while administering medication to Resident 46 who was observed with productive cough. LVN 4 stated she had not previously heard or was reported to her by the other staffs that Resident 46 had productive cough. LVN 4 stated she was not informed to isolate the staff with cough or to wear gown or N95 mask when taking care of the residents with productive cough. A review of Resident 56's admission Record indicated the facility admitted Resident 56 on 12/17/2018 and readmitted the resident on 10/22/2021 with diagnosis of chronic pulmonary edema (fluid in the lungs). A review of Resident 56's physician order dated 11/5/2021, timed at 10:45 pm, indicated to transfer Resident 56 to the GACH for evaluation of cough. During an interview on 11/9/2021 at 12:30 pm, the DON stated a new onset cough or worsened cough was a symptom of respiratory infection such as influenza virus. The DON stated the facility did not perform influenza virus test to the residents (unidentified) with new onset or worsened cough. The DON stated the residents (unidentified) should had been tested because of the current flu season as indicated in the facility's policy and procedure. A review of the admission Record indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 22 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Immediate jeopardy to resident health or safety Residents Affected - Some 53 was admitted to the facility on [DATE] with diagnoses of benign prostatic hyperplasia ( BPH - a condition in which an overgrowth prostate tissue pushes against the urethra and the bladder, blocking the flow of the urine), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 53's MDS dated [DATE], indicated the resident was severely impaired with cognitive skills for daily decision making. During an observation on 11/09/2021 at 9:45 am, together with IPN, observed IPN touched the resident's urinary drainage bag without performing hand hygiene, not wearing gloves, before and after manipulating the resient's urinary tube and drainage bag. IPN stated it was important to don gloves before handling the FC drainage bag to avoid infection to the resident. During an interview on 11/10/2021 at 9:11 am, the DON stated staff were encouraged to wear gloves and perform handwashing before and after touching the residents' urinary bag to prevent infection. A review of the Policy and Procedure (P&P), titled, Urinary Catheter Care, dated 09/2014, P&P indicated to maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. During an observation on 11/10/2021, at 2:55 pm, Resident 209 was coughing productively with her room door open. A review of Resident 209's admission Record indicated the facility admitted Resident 209 on 10/29/2021 with diagnoses that included infection to right hip and joint prosthesis (artificial device). A review of Resident 209's History and Physical dated 10/30/2021, indicated Resident 209 had the capacity to understand and make decisions. During an interview on 11/10/2021 at 4:35 pm, the IPN stated Influenza virus could be transmitted by droplets (such as a particle of moisture discharged from the mouth during coughing, sneezing, or speaking; these may transmit infections while airborne to others). The IPN stated the staff (unidentified) were not required to wear a gown and N95 mask because the residents with cough were not on isolation or quarantined. A review of the facility's policy and procedure, titled Prevention and Control of Seasonal Influenza indicated, traditionally, influenza viruses have been thought to spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a susceptible (at risk) person (approximately six (6) feet or less) through the air. Indirect contact transmission via hand transfer of influenza virus from virus-contaminated surfaces or objects to mucosa (surfaces of the face (e.g., nose, mouth) may also occur. All respiratory secretions and bodily fluids, including diarrheal stools, of residents with influenza are considered to be potentially infectious; however, the risk may vary by strain. A review of the facility's policy and of the Department of Public Health, Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, dated 10/21/2021, indicated every staff member or resident with symptoms of COVID-19 (fever, cough, dyspnea [difficulty breathing], new loss of taste or smell, chills/rigors [tremor], myalgias (muscle pain), (rhinorrhea (runny nose), vomiting or diarrhea, sore throat, fatigue, headache, and confusion) should be tested as soon as possible, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 23 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 - Immediate jeopardy to resident health or safety regardless of vaccination status. The guideline indicated all symptomatic residents should be presumed infectious pending test results and should be in quarantine in a private room in the Yellow Cohort (mixed quarantine and symptomatic residents), if possible. The guideline also indicated during the influenza season, residents with acute respiratory symptoms should also be tested for influenza. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/#cohorting Residents Affected - Some A review of Interim Guideline for COVID-19 Antigen Testing in Skilled Nursing facilities, dated 10/20/2020, indicated symptomatic residents tested for point of care Antigen test with negative results should be confirmed with COVID-19 Polymerase Chain Reaction (PCR) test. The guideline also indicated residents to be quarantined in the Yellow Cohort pending PCR confirmation and when PCR results are confirmed negative, residents can be moved to the green cohort with droplet precautions until after the resident is clinically improved and 24 hours after resolution of fever. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/antigen/ A review of the facility's policy and procedure titled, Influenza, Prevention and Control of Seasonal, dated Revised August 2014, indicated Policy Interpretation and Implementation, Influenza Modes of Transmission, 1. Traditionally, influenza viruses have been thought to spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a susceptible person). a. Transmission via large-particle droplets requires close contact between source and recipient persons because droplets generally travel only short distances (approximately six (6) feet or less) through the air. 2. Indirect contact transmission via hand transfer of influenza virus from virus-contaminated surfaces or objects to mucosal surfaces of the face (e.g., nose, mouth) may also occur. Under Infected Residents and Visitors-3e. During periods of increased community influenza activity, rapid screening of residents for symptoms of influenza and separation from other residents during screening may be necessary. A review of the facility's policy and procedure, titled Isolation-Initiating Transmission Based Precautions revised January 2012, indicated if the resident had symptoms of respiratory infection during the Influenza season, the resident should be tested for Influenza. A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility with diagnoses that included heart failure (failure of the heart to function properly), fluid overload (condition where there is too much fluid in the body), and asthma (a condition in which lung airways narrow and swell and may produce extra mucus). A review of Resident 47's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/17/2021, indicated Resident 47 had the cognitive skills (ability to perceive and react, process and understand, store and retrieve information, make decisions and produce appropriate responses) for decision making. A review of Resident 47's Change of Condition dated 11/10/2021, timed at 11:30 am, indicated Resident 47 had cough and was transferred to the hospital via paramedics for shortness of breath. During an observation and interview on 11/9/2021 at 9:58 am, in the facility's green zone, no PPE signage, inside Resident 47's room, Resident 47 was sitting on the side of her bed receiving a breathing treatment and was coughing. Resident 47 is in a room with a roommate without any isolation precautions in place. Resident 47 stated she was receiving the breathing treatment for her cough that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 24 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 made her chest hurt. Level of Harm - Immediate jeopardy to resident health or safety During an observation on 11/9/2021 at 10:21 am in Resident 47's room, Licensed Vocational Nurse (LVN) 3, LVN 3 entered Resident 47's room to administer breathing treatment and medications. LVN 3 was not wearing an N95 and no gown. Residents Affected - Some During an observation on 11/10/2021 at 9:18 am in Resident 47's room, Certified Nurse Assistant 2 (CNA) 2 was assisting Resident 47's roommate to the restroom. CNA 2 was not wearing gown and N95. During a concurrent observation and interview on 11/10/2021 at 9:21 am with Resident 47, in Resident 47's room, Resident 47 was sitting on the side of her bed asking for her medication and breathing treatment. Resident 47 was heard coughing. Resident 47 was still in a room with a roommate without any isolation precautions in place. Resident 47 stated she was not feeling well and stated she wanted her medication so she could feel better. During an interview on 11/10/2021 at 4:30 pm, IPN stated Resident 47 was transferred to the hospital for episode of shortness of breath earlier on 11/10/2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 25 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure the swamp cooler (pulls in warm surrounding air and pass it to wet media to remove heat and blow the cooler air into the attached duct, at the end of the cooling season this could be drained and their media [evaporative pads] can be dried out for long term storage) located above the kitchen ceiling was in functional condition. This deficient practice resulted in the water to overflow on the facility's kitchen ceiling that dripped near and above the steam table which was used to serve meals for the residents which had the potential for food contamination and mold (a fungus) accumulation on the ceiling. Findings: During an interview on 11/9/2021 at 8:20 am, the facility's Administrator (ADM) stated she was not aware of the crack in the kitchen ceiling. ADM stated if she was informed, she had addressed it right away because it might contaminate the food. During an initial tour observation of the kitchen and an interview, on 11/9/2021 at 9:04 am, the Dietary Supervisor (DS) stated the ceiling had a crack in the ceiling measuring three feet (a unit of length) next to the fluorescent light, with a piece of dry wall hanging above the steam table. Observed the plastic covered of the fluorescent light with yellowish discoloration. DS stated the ceiling started hanging down on 11/7/2021. DS stated there was water that started to drip on 11/3/2021 and she stated she notified the Maintenance Supervisor (MS) on the same day. During an interview on 11/09/2021 at 9:31 am, DS stated she continued to use the steam table while serving food and there was a possibility the debris would contaminate the food during food preparation. DS stated she did not inform the ADM regarding the crack in the ceiling and water leakage. During an interview on 11/9/2021 at 3:37 pm, MS stated on 11/7/2021 at 9:30 pm the water was leaking and dripping in the kitchen ceiling. MS stated the water pump was broken and he just turned off the water system. MS stated he put a two centimeter (cm a unit of measurement) hole in the ceiling and did not open the ceiling to assess the extent of the water damage. MS stated he was not sure if there was molds in the dry wall. MS stated he did not fix it because it was still wet and needed to be dry up. MS stated on 11/8/2021 he placed a bucket to catch the water dripping from the ceiling but did not do anything to fix the crack and leak until 11/9/2021. During an interview on 11/10/2021 at 8:01 am,MS stated he was first informed by the DS on 11/7/2021 and did not inform him prior to that date. MS stated he did not notify the ADM regarding the water leak in the ceiling. A review of the facility's Invoice dated 11/11/2021, indicated the swamp float got stuck and rusted out that caused the water to drip. A review of facility's policy and procedure (P&P) General Safety Precautions dated 12/2009, P&P indicated to follow established safety precautions as well as those that may become necessary or appropriate. P&P indicated to report all unsafe conditions to the supervisor as soon as practical. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 26 of 27 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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 0921 Level of Harm - Minimal harm or potential for actual harm A review of facility's P&P Maintenance service, dated 12/2009, indicated maintenance service should be provided to all areas of the building. P&P indicated the functions of maintenance personnel included to maintain the building in good repair and free from hazards. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 27 of 27