Health inspection·June 10, 2022

F 0686 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with LVN 4, on June 9, 2022, at 1:22 PM, in Resident 61's room, LVN 4 inspected the wound care dressing at Resident 61's sacral area. It was not labeled by the initial of the licensed nurse who rendered the wound care treatment, and the date and time it was provided. LVN 4 stated she labeled the wound care dressing with a date but did not include her initials and the time it was provided. Residents Affected - Few 2. During a review of Resident 693's admission Record, on June 10, 2022, at 11:15 AM, the admission Record indicated Resident 693, was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus, paroxysmal tachycardia (a type of abnormal rhythm), pressure ulcer on the sacral region unstageable (UTD- an ulcer having full thickness tissue loss, in which the base of the ulcer cannot be seen, and thus the depth of the wound) and pressure ulcer of left buttocks stage one (redness). During a review of Resident 693's Physician's Order Sheet, dated June 1, 2022, it indicated, Wound Treatment: Pressure Injury - UTD left posterior thigh. Cleanse with normal saline pat dry apply skin prep and dry dressing q (every) day x 30 days . During a concurrent observation and interview with LVN 5, on June 9, 2022, at 1:14 PM, in Resident 693's room, LVN 5 inspected the wound care dressing at Resident 693's sacral area and left buttocks. The wound dressings were not labeled by the initial of the licensed nurse who rendered the wound care treatment, and time it was provided. LVN 5 stated he did not label the wound care dressings with time because wound care dressing changes was ordered daily. 3. During a review of Resident 53's admission Record, on June 10, 2022, at 11:20 AM, the admission Record indicated Resident 53, was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, and pressure ulcer sacral region stage four. During a review of Resident 53's Physician's Order Sheet, dated June 10, 2022, it indicated, Cleanse sacral coccyx pressure injury with ns pat dry apply Medihoney (honey that is used for burn and wound that has been filtered to a higher level than food grade honey, and has been sterilized) and skin prep to peri wound, cover with dd q day x 30days. Every day shift for 30 days. During a concurrent observation and interview with LVN 4 on June 9, 2022, at 1:25 PM, in Resident 53's room, LVN 4 inspected the wound care dressing at Resident 53's sacral area. It was not labeled by the initial of the licensed nurse who rendered the wound care treatment, and the date and time it was provided. LVN 4 stated she did not label the dressing. 4. During a review of Resident 490's admission Record, on June 10, 2022, at 11:25 AM, the admission Record indicated Resident 490 was admitted to the facility on [DATE], with diagnoses that included edema (swelling) pressure ulcer of left buttocks stage four and pressure ulcer of right buttocks stage four. During a review of Resident 490's Physician's Order Sheet, dated May 10, 2022, it indicated, Wound Treatment: stage four pressure injury right ischium (the curved bone forming the base of each half of the pelvis). Cleanse with NS (Normal Saline)apply collagen and cover with dry dressing every day shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 490's Physician's Order Sheet, dated May 10, 2022, it indicated, Wound Treatment: stage four pressure injury left ischium Cleanse with NS apply collagen and cover with dry dressing every day shift for 30 days. An observation of Resident 490's wound care treatment was conducted on June 9, 2022, at 12:45 PM, in Resident 490's room. LVN 4 rendered wound care treatment on Resident 490's pressure injury on the left and right buttocks. The wound care dressing was labeled with a date. It did not include the initials of LVN 4 and the time it was provided. During a concurrent interview and record review on June 9, 2022, at 2:35 PM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure titled Wound Care dated 2002. The Wound Care policy indicated, Steps in the procedure . 13. Dress wound, pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date and apply to dressing. The DON stated the policy was not followed. The DON further stated her expectation on wound care dressing are dated, timed, and initialed by the licensed nurse who performed the dressing change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 0692 Provide enough food/fluids to maintain a resident's health. 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 maintain acceptable parameters of nutrition status for 2 out of 40 residents (Residents 13 and 62) reviewed for nutrition when: Residents Affected - Some 1. Resident 62 lost 18% of his body weight in the last 6 months. Since September 5, 2021, he had poor food intake. Three different registered dietitians recommended an appetite stimulant on September 28, 2021, October 7, 2021, and March 14, 2022. The appetite stimulant was ordered on April 10, 2022. Consequently, Resident 62 lost 26 pounds during that time. 2. Residents 13 and 62, who were on a fortified diet (diet to increase calories for residents who need to maintain or gain weight) were given fortified cereal for breakfast and fortified mashed potatoes for lunch and dinner daily. These foods were in addition to the foods that were already on the menu. Multiple observations indicated Residents 13 and 62 were not consuming the extra fortified foods provided. This intervention was intended to add additional calories so that residents would either maintain or gain weight. However, a) Resident 13 lost 10 pounds from January 3, 2022, to June 6, 2022. b) Resident 62 lost 23 pounds from January 5, 2022, to June 6, 2022. These failures had the potential to cause additional weight loss and increase Residents 13 and 62 risk of morbidity (the condition of suffering from a disease or medical condition) and mortality (death). A study showed that nursing home residents had a significantly higher mortality rate in the six months after losing 10 percent of their body weight and another study indicated that elderly residents in nursing homes who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. Findings: 1. During an observation on June 9, 2022, 12:20 PM, Resident 62 was in bed. He was able to respond to questions with yes or no. He stated he was not hungry. His food tray was on the side table and appeared untouched. The tray ticket (paper that identifies patient and their diet and food likes, and dislikes) indicated Resident 62 was on a puree diet. A review of Resident 62's face sheet (a document that gives a summary of patient's information) indicated Resident 62 was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and chronic pain. During an interview with the Registered Dietitian (RD 1), on June 10, 2022, at 11:13 AM, the RD 1 stated she did not have a conversation with the Medical Doctor after he did not follow her recommendation to put Resident 62 on an appetite stimulant. She stated she did not question the Medical Doctors rationale for not ordering the appetite stimulant even though the resident continued to have poor meal intake despite multiple supplement and food interventions and continued to lose weight. During a review of Resident 62's Weights, undated, it indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 0692 January 5, 2022 - 127 lbs. (pound- unit of measurement) Level of Harm - Minimal harm or potential for actual harm February 5, 2022 - 132 lbs. March 6, 2022 - 122 lbs. Residents Affected - Some April 4, 2022 - 116 lbs. May 5, 2022 - 116 lbs. June 6, 2022 - 104 lbs. During a review of Residents 62's Monthly Weight Variance, dated September 28, 2021, documented by RD 3, it indicated RD [Registered Dietitian 3] recommends physician review for addition of appetite stimulant and variable PO (by mouth) intake. During a review of Resident 62's Weight Change Progress Note, dated October 12, 2021, documented by RD 2, it indicated, Recommendation: to have an appetite stimulant Megace (brand of appetite stimulant) per MD (medical doctor) consent. And PO (by mouth) intake 26% x 39 meals; resident often refuses to eat. During a review of Resident 62's Weight Change Progress Note, dated March 14, 2022, documented by RD 1, indicated wt (weight) change r/t (related to) poor PO intake; pt (patient) refusing meals consecutively. Recommendation: recommend appetite stimulant per MD order to aid in increasing PO intake. During a review of Resident 62's Weight Change Progress Note, dated April 8, 2022, documented by RD 1, it indicated wt change: significant wt change x three months r/t poor PO intake. Pt refusing meals with poor appetite. Recommend appetite stimulant per MD order to aid with increasing PO intake. During a review of Resident 62's Order Listing Report, dated June 10, 2022, it indicated April 10, 2022 order date and May 27, 2022 discontinued- Remeron (medication for depression also used to stimulate appetite) tablet 15 mg (milligrams) give one tablet by mouth at bedtime for depression m/b (manifested by) loss of appetite. And May 27, 2022 order date - Remeron tablet 15mg .give one tablet by mouth at bedtime for depression m/b self report of sadness. During a review of Resident 62's Nutritional Assessment, dated October 17, 2021, it indicated Assessment: wt change: current wt 116# (pounds) (10/4/21): -7# (-5.7%) x one month; -18# (-13.4%) x three months; -16# (-12.1%) x six months; all are significant (weight loss), d/t (due to) inadequate calorie intake; resident is put on RNA (restorative nursing assistant) feeding program at this time; Average percentage of meals eaten: 56% x 33 meals .Dietary supplements/nutritional interventions/other: Boost (high calorie drink) QD (every day), Health shake (high calorie drink) with meals, prostat (high protein drink) QD; fortified food with lunch and dinner. During a review of Resident 62's Nutritional Assessment, dated April 20, 2022, it indicated Assessment: current wt : (April 4, 2022) 116# ; (April 16, 2022 120#, wt change; significant wt change x three months. Pt (patient) with BMI (calculation using height in weight to determine health risk) underweight, currently on appetite stimulant expected new weight gain, beneficial for pt overall health. Noted increase in PO intake. Average Percentage of meals eaten: 46% x seven days . Dietary Supplements/nutritional interventions/other: HS (Health Shake) BID (two times a day), Prostat BID, Boost TID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 0692 (three times a day), Fortified cereal with breakfast. Level of Harm - Minimal harm or potential for actual harm 2. a) During a concurrent observation and interview with Resident 13, in his room, on June 9, 2022, at 12:45 PM, Resident 13 was sitting up in bed, eating his lunch. Resident 13 did not eat the mashed potatoes that were in a separate bowl to the side of this plate. He stated, I don't like mashed potatoes. His meal ticket on his tray indicated that he was on a regular diet with fortified mashed potatoes for lunch. Residents Affected - Some A review of Resident 13's face sheet indicated he was admitted to the facility on [DATE] with diagnoses that included hydronephrosis (swelling of a kidney due to a build-up of urine), and hypertension (high blood pressure), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) During an interview on June 9, 2022, at 1:15 PM with Dietary Services Supervisor (DSS), the DSS stated the practice of the facility was to serve fortified cereal for breakfast and fortified mashed potatoes for lunch and dinner. She stated the doctor's orders indicate whether they will get the fortified foods and for what meal. She stated if mashed potatoes was not the menu for dinner they will serve a fortified soup. During an interview with a Certified Nursing Assistant (CNA 1), on June 9, 2022, at 1:40 PM, CNA 1 stated Resident 13 gets mashed potatoes every day on his meal trays and sometimes does not eat them. During an interview on June 10, 2022, at 10:30 AM, with the RD 1, the RD 1 stated there was no system in place to document or track if fortified items are being consumed by residents. The RD 1 also stated she had not done any in-service (training) for CNAs on promoting and encouraging fortified items to be consumed first. During an interview with the DSS, on June 10, 2022, at 2:45 PM, the DSS stated the fortified diet facility policy and fortified diet description from the facilities Nutrition Care Manual were not being followed. The DSS stated the intent of the fortified diet was to add calories to the diet without adding additional food. The DSS further stated when the former dietitian was employed, there was going to be a change in the practice of mashed potatoes and cereal as the fortified items to avoid overwhelming the residents with too many food items and redundancy of items. During a record review of Resident 13's medical record, it indicated the following body weights of Resident 13: January 3, 2022, weight 131 pounds February 5, 2022 weight 129 pounds March 6, 2022, weight 124 pounds April 4, 2022, weight 124 pounds May 5, 2022, weight 124 pounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 0692 June 6, 2022, weight 121 pounds Level of Harm - Minimal harm or potential for actual harm During a record review of Resident 13's Physician's Order Sheet, dated May 23, 2022, it indicated Resident 13 had a diet order of Fortified cereal at breakfast and Fortified foods BID with lunch and dinner Residents Affected - Some During a record review of Resident 13's meal tickets (paper include on the tray to indicate what diet the resident is on, and also resident likes and dislikes), dated June 9, 2022, it indicated Breakfast: Fortified cereal - 6 oz (ounces - a unit of measurement), Lunch: Fortified mashed potatoes - 4 oz and Dinner: Fortified mashed potatoes - 4 oz 2. b) During an observation, interview, and record review, on June 9, 2022, 12:20 PM, Resident 62 was lying in bed. He was able to respond to questions with yes or no. He stated he was not hungry. His food tray was on the side table and appeared untouched. The meal ticket indicated Resident 62 was on a puree diet. Each item of the meal was separated into a mug to assist the resident in consuming the food. The menu indicated that he received puree fish with dill sauce, seasoned fries, herbed corn and tomatoes and a wheat roll. An additional mug was on the tray with the fortified mashed potatoes. For a total of 6 mugs with puree food. A review of Resident 62's face sheet indicated Resident 62 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, anxiety, and chronic pain. During an interview with CNA 2, on June 9, 2022, at 12:46 PM, she stated Resident 62 refused lunch today (June 9, 2022). During an interview on June 10, 2022 at 10:30 AM, with the RD 1, the RD 1 stated there is no system in place to document or track if fortified items are being consumed by residents. The RD 1 also stated that she had not done any in-service (training) for CNAs on promoting and encouraging fortified items to be consumed first. During a review of Resident 62's Order Listing Report, dated June 10, 2022, it indicated Resident 62 had an order on April 21, 2022 fortified cereal with breakfast. During a review of Resident 62's Care Plan, untitled, it indicated interventions/tasks: Fortified mashed potatoes BID (two times per day), fortified cereal with breakfast, date initiated September 28, 2022. During a review of the facility's policy and procedure (P&P) titled Fortification of Food: Increasing Calories and/or Protein in the Diet, it indicated a) .Careful thought is to be given to avoid overwhelming the resident with food. b) Reducing the portions to 1/2 size versus small or regular may help a resident who is eating less than 50% of meal. The portions will not be as overwhelming and better consumption may be viewed as an attainable goal for residents. During a review of a document titled Fortified Diet, dated 2020, it indicated The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Further review indicated Example of adding calories may include: Extra margarine or butter to food items such as vegetables, potatoes, hot cereal, break toast, pancakes, waffles, rice, pasta, etc.; Extra gravy and sauces to meats, casseroles, potatoes, rice and pasta; Non-dairy creamer on half and half to drink, or added to hot cereal or soups; Extra mayonnaise (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete added to sandwiches and mayonnaise based salads; Extra jelly on breads; Non-fat dry milk powder added to soups, puddings and drinks; Commercial calorie and/or protein powder added to beverages, puddings, cereals or soups; Top with whipped topping or chocolate sauce; Add cheese to soups, pasta or vegetables. During a review of the article, Evaluating and Treating Unintentional Weight loss in the Elderly, American Family Physician, Volume 64, Number 2, dated February 15, 2002, it indicated nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. Event ID: Facility ID: 055872 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 - Few 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 interview and record review, the facility failed to ensure a process to routinely evaluate staff skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) was implemented for three of four licensed nurses (Registered Nurse 1, Licensed Vocational Nurse 4, and Licensed Vocational Nurse 5). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs. Findings: During an interview on June 10, 2022, at 9:35 AM, with the Director for Staff Development (DSD), the DSD stated he has not done a performance evaluation and skills competencies on any of the staff since he started on this role February 2022. He also stated he has no process of tracking staff competencies and performance evaluations. During an interview on June 10, 2022, at 2:20 PM, with the Administrator and the DSD, the Administrator stated they do not have the following polices: Performance Evaluation and Staff Competencies. During a record review of the employee files, it indicated the following: a. Registered Nurse (RN 1) was hired on February 22, 2019. b. Licensed Vocational Nurse (LVN 4) was hired on July 16, 2013. c. Licensed Vocational Nurse (LVN 5) was hired October 16, 2014. During a concurrent interview and record review with the DSD, on June 10, 2022, at 2:35 PM, the DSD reviewed the employee files of RN 1, LVN 1 and LVN 2, and stated he was unable to find documented evidence to indicate performance evaluation and skills competencies were conducted for the three (3) employees. During a review of an undated facility document titled Facility Assessment Tool, it indicated Staff training/education and competencies, 3.4. If any staff require certification, we validate that it's happened upon hire and routinely thereafter. During a review of the RN Job Description, dated 2003, it indicated, Competency evaluation are required for this position. During a review of the LVN Job Description, dated 2003, it indicated, Competency evaluation are required for this position. The facility was not able to provide a policy and procedure regarding Performance Evaluation and Staff Competencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for four of four medication carts (South, South-Center, North, and North-Center carts). These failures placed the facility at potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 92 residents. Findings: 1. During a concurrent observation and interview on June 9, 2022, at 12:50 PM, with a License Vocational Nurse (LVN 3), the North-Center medication cart's Controlled Drug Inventory (CDI- narcotic records, a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated May 19, 2022, to June 8, 2022, was reviewed. The CDI indicated the following: a. On May 22, 2022, missing signature from the night shift (11:00 PM - 7:00 AM) oncoming nurse and a missing discrepancy count (counting the number of medication present in a particular location compared to the number expected) at 11:00 PM. b. On June 1, 2022, missing signature from the night shift (11:00 PM- 7:00 AM) oncoming nurse. c. On June 7, 2022, missing signature from the night shift (11:00 PM- 7:00 AM) oncoming nurse and missing discrepancy count at 11:00 PM. d. On June 8, 2022, missing signatures from the evening shift (3:00 PM to 11:00 PM) oncoming and evening shift (3:00 PM to 11:00 PM) off going nurses. LVN 3 confirmed missing signatures and missing discrepancy count in the CDI. LVN 3 stated oncoming and off going nurses must sign the form and indicate if there are any missing discrepancy count. 2. During a concurrent observation and interview on June 9, 2022, at 1:00 PM, with LVN 3, the South-Center medication cart's CDI, dated May 6, 2022, to June 9, 2022, was reviewed. The CDI indicated the following: a. On May 7, 2022, missing signature from the day shift (7:00 AM to 3:00 PM) off going nurse. b. On May 8, 2022, missing signature from the day shift (7:00 AM to 3:00 PM) oncoming nurse. c. On May 12, 2022, missing signature from the evening shift (3:00 PM to 11:00 PM) off going nurse. d. On May 26, 2022, missing signature from the night shift (11:00 PM to 7:00 AM) oncoming nurse and missing discrepancy count at 11:00 PM. e. On June 2, 2022, missing discrepancy count at 11:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 f. On June 7, 2022, missing signature from the night shift (11:00 PM to 7:00 AM) oncoming nurse. Level of Harm - Minimal harm or potential for actual harm g. On June 8, 2022, missing signature from the night shift (11:00 PM to 7:00 AM) off going nurse. Residents Affected - Few LVN 3 confirmed missing signatures and missing discrepancy count in the CDI and stated oncoming and off going nurses must sign the form and indicate if there are any missing discrepancy count. 3. During a concurrent observation and interview on June 9, 2022, at 1:06 PM, with a Registered Nurse (RN 1), the South medication cart's CDI, dated May 26, 2022, to June 8, 2022, was reviewed. The CDI indicated the following: a. On June 6, 2022, missing discrepancy count at 11:00 PM. b. On June 7, 2022, missing discrepancy count at 7:00 AM and 11:00 PM. c. On June 8, 2022, missing signature from the day shift (7:00 AM to 3:00 PM) off going nurse and missing discrepancy count at 3:00 PM. d. On June 8, 2022, missing discrepancy count at 11:00 PM. RN 1 confirmed missing signatures and missing discrepancy count in the CDI and stated oncoming and off going nurses must sign the form and indicate if there are any missing discrepancy count. 4. During a concurrent observation and interview on June 9, 2022, at 1:25 PM, with LVN 2, the North medication cart's CDI, dated June 3, 2022, to June 9, 2022, was reviewed. The CDI indicated the following: a. On June 8, 2022, missing discrepancy count at 11:00 PM. b. On June 9, 2022, missing discrepancy count at 7:00 AM. LVN 2 confirmed missing discrepancy count in the CDI and stated oncoming and outgoing nurses must indicate if there are any missing discrepancy count. During a concurrent interview and record review, on June 10, 2022, at 9:22 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY: ID3: CONTROLLED SUBSTANCE STORAGE, dated August 2019, was reviewed. The P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility, in accordance with federal and state laws and regulations . At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including the emergency supply, is conducted by two licensed nurses and is documented. The DON stated the policy was not followed. During a concurrent interview and record review, on June 10, 2022, at 9:26 AM, with the DON, the facility's document titled, Job Description- Licensed Vocational Nurse (LVN), dated 2003, was reviewed. The Job Description indicated, Ensure that narcotic records are accurate for your shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the menu, and serve the correct size of roast beef for the regular texture diets (food with no modifications) for lunch on June 7, 2022. Residents Affected - Few This failure had the potential to impair the nutritional status of 58 out of 92 residents who receive food from the kitchen. Findings: During a concurrent observation and interview, on June 7, 2022, at 11:45 AM, in the kitchen, during lunch tray line (when the cook puts food on the plates for the residents), a [NAME] served two ounces of roast beef for the regular textured diets. [NAME] verified the roast beef should have measured at three ounces per the menu. During a review of the facility's Cooks Spreadsheet - Summer Menus dated June 7, 2022, the spreadsheet menu indicated for lunch as serving size of three ounces of Herb and Spice Roast Beef, the roast beef should have been served for the regular, 2 gm (gram-unit of measurement) Na (sodium), CCHO (consistent carbohydrate diet), Renal diets (special diet for residents with kidney problems), and low fat/cholesterol diets. During a review of the facility's policy and procedure (P&P) entitled Food Preparation, dated 2018, the P&P indicated, 1. To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. 2. A diet scale should be used to weigh meats. 3. It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: Residents Affected - Few 1. There were two open style rodent bait traps which had the potential to contaminate the area if a rodent was trapped. 2. There was a meatball, crumbs and loose trash under the food prep table and black grime and crumbs at the side of the stove which had the potential for microorganism (small organism like bacteria, virus, or fungus) growth and attract pests. 3. The underside of the dishwasher counter had a patch and repair area with foam installation and a T-shaped piece of wood supporting the counter. This area was not smooth and easily cleanable, which could lead to microorganism growth that could inadvertently be transferred to food. These failures had the potential to cause foodborne illness in a highly susceptible population of 92 residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Dietary Services Supervisor (DSS), on June 7, 2022, at 8:44 AM, in the kitchen, there was an open wire mesh rodent trap under the lower cabinets. The DSS stated she does not handle the rodent traps, and a company comes once a month to check and maintain them. During an observation on June 8, 2022, at 11:00 AM, in the kitchen, under the counter in the dishwashing area there was an open rodent snap style trap. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 7-206.12 Rodent Bait Stations. Rodent bait shall be contained in a covered, tamper-resistant bait station. 2. During an observation and concurrent interview with the DSS, on June 7, 2022, at 8:46 AM, in the kitchen, there was a meatball, crumbs, and loose trash under food prep table. The DSS stated the meatball and trash should have been cleaned up when the meatball was dropped the night prior. During an observation and concurrent interview with the DSS, on June 7, 2022, at 8:50 AM, in the kitchen, there was black grime and crumbs at the side of the stove. The DSS stated the area should be kept clean. During a review of the facility's policy and procedure (P&P) titled General Appearance of Food & Nutrition Department, dated 2018, the P&P indicated a. Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition. b. Floors must be mopped at least once per day. c. Sweep the floor, pushing all debris forward. Use a dustpan to remove and disposed of debris as it accumulates. d. Mop under and around equipment, along the walls and in corners. Wipe all splash and soil mark from baseboards and walls. e. Wipe up all spills as they occur. During a review of the facility's policy and procedure (P&P) titled Food Borne Illness Outbreak, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 2018, the P&P indicated, Important Factors Which Lead to Many Foodborne Illness Outbreak: Insects and Rodents: Failure to eliminate pest breeding or entry areas; failure to eliminate grime, spilled food, breeding and nesting attractions for pest. 3. During an observation on June 8, 2022, at 11:00 AM, in the kitchen, the counter under the dishwasher had a patch and repair area with foam insulation in the corner and the underside of the counter was supported with a T-shaped piece of wood. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 4-202.16 Nonfood-Contact Surfaces. Non FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control practices when a Registered Nurse (RN 1) did not wear gloves when disconnecting the IV (a thin bendable tube that slides into one of your veins) tubing on June 10, 2022, for one of six residents (Resident 53) reviewed for intravenous therapy in accordance with the facility's policy and procedure. Residents Affected - Few This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to Resident 53. Findings: 1. During a review of Resident 53's admission Record (clinical record with demographic information), the admission Record indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses which included acute pancreatitis (a condition where the pancreas becomes inflamed (swollen) over a short period of time), gastrostomy (is a tube inserted through the belly that brings nutrition directly to the stomach) status, Stage 4 pressure ulcer of sacral region (wound involving full-thickness skin loss potentially extending into the subcutaneous tissue layer). During a review of Resident 53's Physician's Order Sheet, dated May 10, 2022, it indicated Resident 53 had an order to receive 1,000 ml (milliliter is a smaller metric unit that represents the volume or the capacity of a liquid) of normal saline (a mixture of sodium chloride and water) for hydration twice a day via peripheral IV site (cannula/catheter inserted into a small peripheral vein for therapeutic purposes such as administration of medications or fluids). During an observation for Resident 53's wound care treatment, with Licensed Vocational Nurse (LVN 1) and a Restorative Nurse Assistant (RNA 1), on June 10, 2022, at 10:45 AM, in Resident 53's room, Registered Nurse (RN 1) came inside the room and turned off Resident 53's IV infusion pump (a medical device that delivers fluids, such as nutrients and medications, into a patient's body in controlled amounts). She disconnected Resident 53's IV tubing from her peripheral IV line. RN 1 was not wearing gloves. LVN 1 and RNA 1 asked RN 1 if she wanted gloves and she did not respond. During an interview on June 10, 2022, at 11:00 AM, with RN 1, RN 1 was asked if she should be wearing gloves when hanging IVs, RN 1 stated, Yes, I knew it when I entered the room [Resident 53's room] but I wanted to hurry and stop the machine from beeping. During record review of the facility's undated policy and procedure, titled 3. Infection Control, Universal Precautions, it indicated 5. It is imperative to wash hands prior to and immediately after a procedure .7. Gloves shall be worn during all IV therapy procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055872 If continuation sheet Page 15 of 15