Health inspection·February 11, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. 2. Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values ( e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity). 3. Resident's fluid loss exceeds the amount of fluids they take in (e.g., loss from vomiting, fever, diarrhea that exceeds fluid replacement). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on observation, interview, and record review, the facility failed to develop and implement person-centered care-plans for 3 of 3 (Resident 46, Resident 35 and Resident 38) sampled residents when: a. There was no care plan created for Resident 46 who was diagnosed with abdominal distension (swollen belly, enlarged). b-c. For Resident 35 and Resident 38, the facility did not follow an existing care plan's intervention to trim, and clean Resident 35's and Resident 38's nails on bath day and as necessary. These failures had the potential to result in inconsistent implementation of care and had the potential to result in physical declines to Residents 46, 35, and 38 and result in infections to Residents 35 and 38. Cross Reference: F677 Findings: a.During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was re-admitted to the facility on [DATE] with diagnoses that included end stage renal disease (last stage of kidney loss) and hypertension (high blood pressure). During a review of Resident 43's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 12/11/23, the MDS indicated Resident 43 had clear speech and had moderate cognitive (ability to understand and process information) impairment. During a review of Resident 46's Progress Notes, dated 1/23/24 timed at 10:26 pm., the PNs indicated Resident 46 was being monitored for abdominal distention. During a review of Resident 46's Ultrasound of the Abdomen (USA), dated 1/23/24, The USA's indication was distention. During an interview and concurrent record review of Resident 46's paper and electronic medical record, with Licensed Vocational Nurse 1 (LVN 1) on 2/10/24 at 2:37 pm, LVN 1 stated Resident 46 did not have a care plan regarding abdominal distension or ascites (swelling of the abdomen caused by fluid buildup). LVN1 stated care plans were important to show what the facility did, the goals in place, and what needed to be addressed. During an interview with Registered Nurse 1 (RN 1) on 2/10/24 at 2:38 pm, RN 1 stated starting and implementation of care plans was important to determine what interventions were done and what else needed to be followed for the safety of the residents (in general). b.During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included immunodeficiency (failure of the immune system to protect the body from infection), polyneuropathies (simultaneous malfunction of many peripheral [away from the center] nerves throughout the body), and type (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some two diabetes (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 35's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 12/24/2023, the MDS indicated Resident 35 had moderately impaired cognition (ability to think, remember, and function). The MDS indicated Resident 35 was dependent (helper does all the effort and the resident [in general] does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 35 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs [arms or legs] and provides more than half effort) with upper body dressing and personal hygiene. During a review of Resident 35's care plan initiated 11/10/21 and revised 1/18/24, the care plan indicated Resident 35 had a functional ability performance deficit related to polyneuropathy, impaired balance, history of falling, antidepressant (medication used to treat depression) use, and history of fibula (shin bone) fracture (break in bone). The care plan indicated Resident 35 would maintain current level of function that included personal hygiene. The care plan included interventions, to check Resident 35's nail length, trim, and clean on bath day and as necessary. During an observation on 2/9/24 at 6:48 pm., Resident 35 was lying in bed and Resident 25's nails on both hands were long, overgrowth, and had dark dirt-like particles underneath. During a concurrent observation and interview on 2/10/24 at 1:27 pm., with CNA 4, Resident 35's fingernails were observed. CNA 4 stated Resident 35's fingernails were long and had dirt underneath the nails. CNA 4 stated resident (in general) were supposed to be trimmed every Wednesday. CNA 4 stated fingernails were supposed to be kept trimmed and clean, so they don't hold bacteria and spread infections [to the residents]. c.During a review of Resident 38's AR, the AR indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) following cerebral infarct (disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain) of the right side, and DM 2. During a review of Resident 38's MDS, dated [DATE], the MDS indicated Resident 38 had severe impaired cognition. The MDS indicated Resident 38 was dependent with eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 38's care plan initiated 9/15/22, revised 1/17/24, the care plan indicated Resident 38 had a functional ability deficit due to confusion, hemiplegia, impaired balance, and contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) on the right hand. The care plan indicated interventions, to check Resident 38's nail length, trim, and clean on bath day and as necessary. During an observation on 2/9/2024 at 6:48 pm, Resident 38's fingernails were long, overgrown, and dirt-like particles were underneath Resident 38's fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 2/10/24 at 1:14 pm, with CNA 2, Resident 38's fingernails were observed. CNA 2 stated Resident 38's left fingernails were long and dirty. CNA 2 stated Resident 38's right fingernails were long, but clean. During an interview on 2/10/24 at 2:33 pm, with the Director of Staffing Development (DSD), the DSD stated fingernails and toenails needed to be kept clean and trimmed to prevent alterations in skin integrity (skin being a sound and complete structure, unimpaired condition), skin tears (a wound that happens when the layers of skin separate or peel back), and skin infections. The DSD stated if residents' (in general) fingernails were long and dirty, residents could potentially be introducing infections into their mouths. The DSD stated if residents developed infections from dirty nails, residents could get sepsis (the body's extreme response to infection, a life-threatening medical emergency) and need hospitalization. During an interview on 2/10/24 at 4:48 pm, with the Director of Nursing (DON), the DON stated CNAs cut residents' fingernails and podiatry (medical professional who specializes to the treatment of the foot, ankle, and related structures of the leg) cut residents' toenails. The DON stated nail care was to be performed every Wednesday. The DON stated if fingernails and toenails were not kept cleaned and trimmed, there was a potential for residents to develop skin breakdown, fungal infections, and injuries. The DON stated it was important to follow a resident's care plan because it was a pathway for treatment. The DON stated if a care plan's interventions were not followed, it could lead to negative resident outcomes. During a review of the facility's policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the PP indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial (mental, emotional, social, and spiritual effects), and functional needs was developed and implemented for each resident. The PP indicated the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The PP indicated residents had the right to receive the services and/or items included in the plan of care. During a review of the facility's PP titled, Fingernails/Toenails, Care of, revised 2/2018, the PP indicated the purpose of the PP was to ensure clean nail beds, to keep nails trimmed, and to prevent infections. The PP indicated nail care included daily cleaning and regular trimming. The PP indicated proper nail care aided in the prevention of skin problems around the nail bed. The PP indicated trimmed and smooth nails prevented residents from accidentally scratching and injuring his or her skin. The PP indicated the date, time, and name and title of the individual who performed the nail care should be recorded in the residents' medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary grooming services were provided for three of six sampled Residents (Residents 3, 35, and 38) Residents Affected - Some as indicated in the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, by failing to: 1. Ensure Resident 3, who had a left contracted (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) hand, had trimmed and clean fingernails. 2. Ensure Resident 35's fingernails and toenails (hard, smooth covering that protects the upper part of the end of a toe) were kept trimmed and clean. 3. Ensure Resident 38's fingernails were kept trimmed and clean. The failures resulted in Resident 3's fingernails pressing into Resident 3's left palm (part of hand between the bases of the fingers and the wrist), causing pain and discomfort to Resident 3. The failures had the potential to result in the development of infections and injuries to Resident's 3, 35, and 38 Cross Reference: F656 Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included unspecified (born with condition) deformities (body part not in the normal shape due to injury, illness, or being born with) of left fingers, lack of coordination (uncoordinated movement due to muscle control that causes an inability to coordinate movements), and abnormalities of gait (walk) and mobility (inability to walk normally due to injuries or underlying conditions). During a review of Resident 3's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 1/27/2024, the MDS indicated Resident 3 had intact cognition (ability to think, remember, and function) and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with personal hygiene, putting on/taking off footwear, upper and lower body dressing, and showering/bathing self. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with toileting hygiene and oral hygiene. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) with eating. During a concurrent observation and interview on 2/9/24 at 4:35 pm, with Resident 3, Resident 3's left fingernails were long, overgrown, and pressing into the left palm of Resident 3's hand. Resident 3 stated it [the overgrown nails] were bothering Resident 3 and the left fingernails were pressing into Resident 3's palm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 2/10/24 at 10:27 am, Resident 3's fingernails on the left hand were long and overgrown. During a concurrent observation and interview on 2/10/2024 at 11:14 am, with Certified Nurse Assistant (CNA) 3, Resident 3's fingernails on the left hand were observed. CNA 3 stated Resident 3's fingernails on the left hand were long and were pressing into Resident 3's palm. CNA 3 stated Resident 3's palm was red. CNA 3 stated Resident 3's left fingernails had not been cut in several weeks. CNA 3 stated, in general, CNAs cut resident fingernails. During a concurrent observation and interview on 2/10/2024 at 11:22 am, with Treatment Nurse (TN) 1, Resident 3's fingernails on the left hand were observed. TN 1 stated Resident 3's left fingernails were long and dirty. TN 1 stated the first, (thumb), second (index), fourth (ring), and fifth (pinky) fingernails were pressing into the palm. TN 1 stated the top layer of Resident 3's skin on Resident 3's palm was broken. TN 1 stated Resident 3's palm was reddened from the nails pressing into the skin. TN 1 stated fingernails needed to be kept clean and short because Resident 3 was at risk for infection. TN 1 stated TN 1 did not know when Resident 3's left fingernails were last cut. TN 1 stated fingernails were supposed to be cut weekly. During an interview on 2/10/2024 at 11:16 am, Resident 3 stated Resident 3's left palm hurt. 2. During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included immunodeficiency (failure of the immune system to protect the body from infection), polyneuropathies (simultaneous malfunction of many peripheral [away from the center] nerves throughout the body), and type two diabetes (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 35's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 12/24/2023, the MDS indicated Resident 35 had moderately impaired cognition (ability to think, remember, and function). The MDS indicated Resident 35 was dependent (helper does all the effort and the resident [in general] does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 35 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs [arms or legs] and provides more than half effort) with upper body dressing and personal hygiene. During a review of Resident 35's care plan initiated 11/10/21 and revised 1/18/24, the care plan indicated Resident 35 had a functional ability performance deficit related to polyneuropathy, impaired balance, history of falling, antidepressant (medication used to treat depression) use, and history of fibula (shin bone) fracture (break in bone). The care plan indicated Resident 35 would maintain current level of function that included personal hygiene. The care plan included interventions, to check Resident 35's nail length, trim, and clean on bath day and as necessary. During an observation on 2/9/24 at 6:48 pm., Resident 35 was lying in bed and Resident 35's nails on both hands and toenails were long, overgrown, and had dark dirt-like particles underneath. During a concurrent observation and interview on 2/10/24 at 1:27 pm., with CNA 4, Resident 35's fingernails were observed. CNA 4 stated Resident 35's fingernails were long and had dirt underneath the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nails. CNA 4 stated resident (in general) were supposed to be trimmed every Wednesday. CNA 4 stated fingernails were supposed to be kept trimmed and clean, so they don't hold bacteria and spread infections [to the residents]. During a concurrent interview and record review on 2/10/2024 at 1:43 pm, with Licensed Vocational Nurse (LVN) 1, Resident 35's progress note from podiatry (foot physician) was reviewed. LVN 1 stated the last time Resident 35's toenails were trimmed by the podiatrist (medical professional who specializes to the treatment of the foot, ankle, and related structures of the leg) was on 8/28/23. 3. During a review of Resident 38's AR, the AR indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) following cerebral infarct (disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain) of the right side, and DM 2. During a review of Resident 38's MDS, dated [DATE], the MDS indicated Resident 38 had severe impaired cognition. The MDS indicated Resident 38 was dependent with eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 38's care plan initiated 9/15/22, revised 1/17/24, the care plan indicated Resident 38 had a functional ability deficit due to confusion, hemiplegia, impaired balance, and contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) on the right hand. The care plan indicated interventions, to check Resident 38's nail length, trim, and clean on bath day and as necessary. During an observation on 2/9/24 at 5:03 pm, Resident 38's fingernails were observed to be long, overgrown, and dark dirt-like particles were underneath Resident 38's fingernails. During an observation on 2/9/24 at 6:48 pm, Resident 38's fingernails were long, overgrown, and dark dirt-like particles were underneath Resident 38's fingernails. During a concurrent observation and interview on 2/10/24 at 1:14 pm, with CNA 2, Resident 38's fingernails were observed. CNA 2 stated Resident 38's fingernails on the left hand were long and dirty. CNA 2 stated Resident 38's fingernails on the right hand were long, but clean. During an interview on 2/10/24 at 2:33 pm, with the Director of Staffing Development (DSD), the DSD stated fingernails and toenails needed to be kept clean and trimmed to prevent alterations in skin integrity (skin being a sound and complete structure, unimpaired condition), skin tears (a wound that happens when the layers of skin separate or peel back), and skin infections. The DSD stated if residents' (in general) fingernails were long and dirty, residents could potentially be introducing infections into their mouths. The DSD stated if residents developed infections from dirty nails, residents could get sepsis (the body's extreme response to infection, a life-threatening medical emergency) and need hospitalization. During an interview on 2/10/24 at 4:48 pm, with the Director of Nursing (DON), the DON stated CNAs cut residents' fingernails and podiatry cut residents' toenails. The DON stated nail care was to be performed every Wednesday. The DON stated if fingernails and toenails were not kept cleaned and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some trimmed, there was a potential for residents to develop skin breakdown, fungal infections, and injuries. The DON stated it was important to follow a resident's care plan because it was a pathway for treatment. The DON stated if a care plan's interventions were not followed, it could lead to negative resident outcomes. During a review of the facility's P&P titled, Fingernails/Toenails, Care of, revised 2/2018, the P&P indicated the purpose of the P&P was to ensure clean nail beds, to keep nails trimmed, and to prevent infections. The P&P indicated nail care included daily cleaning and regular trimming. The P&P indicated proper nail care aided in the prevention of skin problems around the nail bed. The P&P indicated trimmed and smooth nails prevented residents from accidentally scratching and injuring his or her skin. The P&P indicated the date, time, and name and title of the individual who performed the nail care should be recorded in the residents' medical record. During a review of the P&P titled, Activities of Daily Living (ADL- the tasks of everyday life fundamental to caring for oneself, revised 3/2018, the P&P indicated residents who were unable to carry out ADLs independently would be provided with care, treatment, and services as appropriate to maintain good nutrition, grooming, and personal and oral hygiene. The P&P indicated appropriate care and services included support and assistance with hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assistive hearing devices were available for one of one sampled resident (Resident 15) who was hard of hearing (HOH). Resident 15 was not provided with audiology (health care professionals who identify, assess, and manage disorders of hearing, balance, and other neural systems) services to address Resident 15's hearing impairment. Residents Affected - Some This failure had the potential to result in further hearing loss and a psychosocial decline to Resident 35 and the potential to affect Resident 15's quality of life. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included hearing loss of unspecified ear, subsequent (occurring) falls, and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 15's Admission/readmission Data Tool (ARDT), dated 9/15/23, the tool indicated Resident 15's ability to hear (with hearing aid or hearing appliances if normally used) was moderately difficult. The tool indicated Resident 15 used hearing aids on Resident 15's left and right ears. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 12/18/23, the MDS indicated Resident 15 had clear speech, and sometimes made self-understood (ability to make request) and sometimes understood others (responds adequately to simple direction.) During a review of Resident 15's Care Plan (CP a summary of health conditions, specific care needs and current treatments), initiated on 10/4/23, the CP indicated Resident 15 had a communication problem due to a hearing deficit, the CP's interventions indicated to anticipate and meet Resident 15's needs and discuss with resident/family concerns or feelings regarding communication difficulty. During an observation on 2/10/24 at 9:26 am., Resident 15 was sitting at the side of Resident 15's bed, asked the surveyor to move closer to Resident 15, and stated, what did you say? During an interview and concurrent review of Resident 15's paper and electronic medical record, with Registered Nurse 1 (RN 1) on 2/10/24 at 2:07 pm, RN 1 stated Resident 15 had trouble hearing others. RN 1 stated Resident 15 had a known issue and was hard of hearing. RN 1 stated, we (the facility) needed to address that issue right away and [currently] there were no physician orders for Resident 15 to be assessed by an Ear Nose and Throat (ENT, a healthcare specialist who treats conditions affecting your ears, nose and throat) doctor. An ENT order should have been obtained so Resident 15 could be assessed for the need of hearing aids to better communicate with the staff. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/10/24 at 2:16 pm, LVN 1 stated when communicating with Resident 15, [staff] needed to raise your voice and stand directly in front of Resident 15 for Resident 15 to hear you. LVN 1 stated Resident 15's physician should have been informed Resident 15 was HOH and inquire if an ENT consultation for hearing aids was needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and concurrent interview with Resident 15, in Resident 15's room, on 2/10/24 at 4:34 pm, Resident 15 gestured for surveyor to come closer to the Resident 15 and stated in a loud voice What did you say? Resident 15 asked surveyor to repeat the question and raised Resident 15's voice and stated, I would like to have hearing aids! So, I can hear! During an interview with Resident 34 (Resident 15's wife and roommate), in Resident 15 and 34's room on 2/10/24 at 4:35 pm, Resident 34 stated Resident 15 had hearing aids at home and will use the hearing aids if he had them here (facility). He [Resident 15] used to use them at home. During an interview with RN 1, on 2/10/24 at 4:54 pm, RN 1 stated it was important to address Resident 15's HOH for [Resident 15 to have a] better quality of life because hearing was the one of the things we (in general) enjoy in life. During an observation on 2/10/24 at 5:09 pm., in the hallway outside Resident 15's room, Resident 15's volume on Resident 15's television could be heard across the hallway. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 2/10/24 at 6:59 pm, LVN 2 stated Resident 15 was HOH and did not have hearing aids. LVN 2 stated when attempting to communicate with Resident 15, LVN 2 needed to raise LVN 2's voice and speak louder for the Resident 15 to hear. A review of the facility's undated policy, titled Hearing Impaired Residents, Care of indicated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other resident and visitors. Staff will assist the resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. Staff will assist resident with care and maintenance of hearing devices. Staff will help residents who have lost, or damaged [NAME] devised in obtaining services to replace the devices. A review of the facility's policy titled Accommodation of Needs, revised on 3/2021, indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift in one of one Nursing Stations (Nursing Station 1) as indicated in the facility's Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised August 2022. Residents Affected - Few This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents. Findings: During a concurrent interview and record review on 2/10/24 at 4:44 p.m. with the Director of Staff Development (DSD), the facility's Daily Direct Care Staffing, dated 2/10/24 was reviewed. The DSD stated a Daily Direct Care Staffing was posted at Nurses Station 1. The DSD stated a Licensed Vocational Nurse (LVN) from the night shift, or the Director of Nursing (DON) posted the document in Nurses Station 1. The DSD stated the Daily Direct Care Staffing only indicated the projected staffing level and did not reflect accurate staffing levels if a staff person called off. During a review of the facility's P&P titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, the P&P indicated, Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The P&P indicated, 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 and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (%) or greater during medication administration observation. The facility had 25 medication administration opportunities observed and two of the 25 medications administered resulted in a medication error rate of 8%. The errors consisted of: Residents Affected - Some a. For Resident 33, who had a gastrostomy tube (GT- tube inserted through the belly that brings nutrition directly to the stomach) and who could not receive solid textures by mouth, the facility failed to ensure the physician's order indicated administration of Bactrim by GT, the order indicated an incorrect route to administer by mouth to Resident 33. b. For Resident 4, the facility failed to administer Peridex (a medication that treats gum disease) as indicated by pharmacy recommendations to Resident 4. These failures had the potential to result in adverse drug events (injuries resulting from medication use including physical and mental harm, or loss of function) and physical declines to Residents 33 and 4. Findings: a. During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was admitted to the facility on [DATE], with diagnoses of dysphagia (difficulty swallowing foods or liquids), oropharyngeal phase (difficulty with or inability to swallow), functional quadriplegia (the complete inability to move due to severe disability frailty caused by another medical condition without physical injury or damage to the spinal cord), and gastrostomy (a surgical opening into the stomach for feeding) status. During a review of Resident 33's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 11/15/23, the MDS indicated Resident 33 had severe impaired cognition (ability to think, remember, and function). The MDS indicated Resident 33 had a swallowing disorder that caused coughing or choking during meals or when swallowing medications, and Resident 33 complained of difficulty or pain with swallowing. During a review of Resident 33's Order Summary Report (OSR), active orders as of 2/11/24. The OSR included a physician's order, dated 1/30/24 that indicated Bactrim DS (antibiotic) oral (by mouth) tablet (pill) 800-160 milligram (mg- unit of measurement), give 1 tablet by mouth one time a day for urinary tract infection (UTI- infection of the urine tract) prophylaxis (PPX- for prevention) and an order, dated 9/27/23 that indicated no solid textures (edible items) for Resident 33. During a concurrent interview and observation on 2/11/24 at 9:41 am, of Resident 33's medication administration with Licensed Vocational Nurse (LVN) 3, Resident 33's medication administration was observed. LVN 3 showed the label of Bactrim DS. The label indicated to give Bactrim DS by mouth and to take the medication with plenty of water. LVN 3 crushed the Bactrim DS, mixed it with water, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0759 administered Bactrim to Resident 33 by GT. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 2/11/24 at 10:57 am, with LVN 3, Resident 33's Bactrim DS medication order was reviewed. LVN 3 stated Resident 33's Bactrim DS order indicated to give the medication by mouth. LVN 3 stated all of Resident 33's medications were supposed to be given by GT. LVN 3 stated it was important to ensure the medication orders and route (way a resident takes medication) were correct to ensure medication and patient safety. LVN 3 stated if Resident 33 was given Bactrim DS by mouth, as ordered, Resident 33 could get hurt. LVN 3 stated Resident 33 could have aspirated (when something enters the airway or lungs by accident) the pill and [this could have] caused aspiration pneumonia (infection that inflames the air sacs of the lungs). Residents Affected - Some During an interview on 2/11/2024 at 3:01 pm, with Registered Nurse 1 (RN 1), RN 1 stated it was important to check medication orders before administering medications to ensure accuracy with medication administration. RN 1 stated nurses were supposed to check the medication orders to ensure the route was correct to prevent medication errors. RN 1 stated if a medication indicated to give by mouth, but a resident received medications by GT, the order needed to be clarified by a physician and a new order should be written. RN 1 stated Resident 33 was not supposed to [receive] medications by mouth and it was ordered by mouth, they [Resident 33] was at risk for aspiration. b. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was readmitted to the facility on [DATE] with diagnoses that included diabetes (elevated blood sugar) and morbid obesity (excessive accumulation of fat). During a review of Resident 4's History and Physical (H&P), dated 8/30/21, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Order Summary Report with active orders as of 2/11/24, the report included a physician's order, dated 9/6/23, the order indicated Peridex Solution .12%, give 15 milliliters (ml, unit of measurement) by mouth every morning and at bedtime for gingivitis (gum disease, causes inflamed gums), the order indicated to rinse and spit. During medication observation, with Licensed Vocational Nurse 1 (LVN 1) on 2/11/24 at 9:11 am, LVN 1 prepared 15 ml's of Peridex (cholorhexidine cluconae oral rinse usp, 0.12%) for and this was Resident 4's last medication to be administered. LVN 1 instructed Resident 4 to rinse Resident 4's mouth with Peridex for 15 seconds and spit out the medication. LVN 1 was observed feeding apple sauce to Resident 4 and Resident 4 drank a glass of water immediately after spitting out Peridex. During a review of Resident 4's Peridex medication label, the label indicated Caution read warning: do not eat, drink or rinse mouth for at least 30 minutes after use. During an observation and concurrent interview with LVN 1, in front of LVN 1's medication cart on 2/11/24 at 10:49 am, LVN 1 read the facility pharmacy recommendation on Resident 4's Peridex bottle and stated the apple sauce and water should have been held for at least 30 minutes after [administration of] Peridex. LVN 1 stated pharmacy recommendations should be followed so Resident 4 could get the full effect of the medication. During an interview with Registered Nurse 1 (RN 1) on 2/11/24 at 3:07 pm, RN 1 stated pharmacy recommendations should be followed to prevent possible side effects and to ensure effectiveness of the medication [was achieved]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 4/2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P indicated if a dosage if believed to be inappropriate or excessive for a resident, or a medication had been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The P&P indicated the individual administering the medications checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The P&P indicated as required or indicated for a medication, the individual administering the medication records in the resident's medical record: the route of administration. Event ID: Facility ID: 055817 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure infection prevention and control practices were included in the facility's, Water Management Program (WMP, a program develop to identify hazardous conditions and taking steps to minimize the growth and transmission of Legionella [bacteria that causes severe lung inflammation called Legionnaires' disease, LD]) and other waterborne pathogens [living thing that causes disease]) by failing to: Residents Affected - Few Develop specific control measures per facility risk area used to control the introduction and/or spread of Legionella. These failures could potentially result in the growth of Legionella and other opportunistic waterborne pathogens and had the potential to result in the development and transmission of LD which could compromise the health and safety of all residents residing at the facility. Findings: During a concurrent interview and record review on 2/11/24 at 12:51 pm, with the Maintenance Supervisor (MS), the facility's, Water Management Program (WMP), was reviewed. The MS stated Legionella could grow and spread in sinks, showers, ice machines, water heaters, and kitchen appliances. The MS stated the facility's control measure to decrease the risk of Legionella growth was to maintain the water temperatures at 118 degrees Fahrenheit (unit of measurement). The MS stated control measures included testing the water temperatures and ensuring water flow. During a concurrent interview and record review on 2/11/24 at 1:05 pm, with the MS, the facility's, WMP, was reviewed. The MS stated there were no control measures in the facility's WMP, in place for each specific at-risk area within the facility for Legionella growth. During a review of the Center for Clinical Standards and Quality/Survey & Certification Group, dated 6/2/2017, revised 6/9/2017, from the Department of Health & Human Services-Centers for Medicare& Medicaid Services (CMS), the document indicated Legionella Infections can cause a serious type of pneumonia (infection that inflames the air sacs of the lungs) called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic [long standing] lung disease or immunocompromised (suppressed immune system, defenses). Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs. Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. The skilled nursing facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The expectations for health care facilities included, CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. During a review of the facility's policy and procedure (P&P) titled, Legionella WMP, revised 9/2022, the P&P indicated the facility was committed to the prevention, detection, and control of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2024 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 - Minimal harm or potential for actual harm waterborne contaminants, including Legionella. The P&P indicated the purposes of the WMP were to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaire's disease. The P&P indicated specific measures used to control the introduction and/or spread of Legionella (like temperature, disinfectants) were to: Residents Affected - Few 1. The control limits or parameters that are acceptable and that are monitored; 2. A diagram of where control measures are applied; 3. A system to monitor control limits and the effectiveness of control measures; 4. A plan for when control limits are not met and/or control measures were not effective; and 5. Documentation of the program The P&P indicated, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP machines, hydrotherapy equipment, etc. The P&P indicated, specific measures were used to control the introduction and /or spread of LD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055817 If continuation sheet Page 17 of 17