Health inspection·March 12, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few 11:36 AM, Resident 1 was noted with discoloration and bruising on the upper part of the left arm but denied feeling any pain. To prevent further movement of the affected arm, staff placed a rolled-up blanket for support. An ice pack was offered to help with swelling, but the resident declined. The doctor and Director of Nursing (DON) were notified, and the doctor ordered an emergency (STAT) X-ray of the left shoulder and upper arm to check for any fractures or injuries. During a review of the X-ray Result report dated 3/7/2025 timed at 2:59 PM, indicated Resident 1 had a fracture in his left upper arm bone near the shoulder that was described as acute impacted and displaced fracture. A review of the physician order dated 3/7/2025, not timed, indicated to transfer Resident 1 to the hospital due to left shoulder fracture. During a review of Resident 1's Progress' Note, dated 3/7/2025 at 9:38 AM, the Progress Note indicated Resident 1 has a new aching pain in the left upper arm, rated as moderate 5/10 (pain scale 0-no pain and 10-severe pain). The note indicated Resident 1's pain occurs occasionally, has rarely affected sleep, and has sometimes limited Resident 1's daily activities and the resident has voiced complaints of pain. A review of the GACH dated 3/7/2025 timed at 8:19 PM indicated to refer Resident 1 to an orthopedic surgeon (doctors specialized in diagnoses, treatment, and performs surgery on conditions affecting the musculoskeletal system including bones, joints, ligaments, tendons, muscles, and nerves) as soon as possible, ideally one-week further evaluation on the proximal humerus fracture found on X-ray today which sustained last week. The GACH discharge record indicated to administer Tramadol 50 milligrams tablet to be given by mouth every six hours as needed for three times daily. During a review of Resident 1's Progress' Note, dated 3/7/2025 at 9:29 PM the Progress Note indicated Resident 1 was being monitored after a left shoulder fracture. Resident 1 arrived in the facility stable, alert, and able to communicate. Resident 1 reported mild pain (3/10) and was prescribed Tramadol (a pain medication) but chose to take medication until bedtime. Resident 1 had bruising present on the left upper arm, unable to move the arm due to a prior contracture, and there was no swelling noted. Two staff members assisted Resident 1 with care for safety, and repositioning was done every two hours for comfort and skin protection. Resident 1's medications have been well tolerated. During a review of the investigation report dated 3/7/25, timed 12 midnight, indicated Resident 1 had pain level of 7/10 and skin discoloration. The report indicated Resident 1 reported that last week before he was sent to the hospital a different guy came to change him who was very rough from the beginning. Resident 1 stated I said please be gentle, I have body pain due to my arthritis and he said, shut up. I will change you the way I change other people. He turned me to the side and that was when he really pulled me by my arm. It hurt so bad. I screamed. He said shut up. The he pushed me hard. It was very painful. He told me to turn. I told him I cannot, and he purposely pulled my legs open. I cannot open my legs because of arthritis. I hurt so bad. The report indicated Resident 1 said something in a foreign language and when asked the guy what he said, He said I am finished with you and walked away. During a concurrent observation and interview on 3/11/2025 at 9:50 AM, with Resident 1, in Resident 1's room, Resident 1 was observed lying on his bed with visible discomfort and extensive bruising and discoloration in various shades of deep purple, red, and yellow on his left elbow, arm and shoulder with contractures on all extremities. In an interview Resident 1 stated, he was feeling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056322 If continuation sheet Page 2 of 4 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 056322 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave Montrose, CA 91020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few discomfort and pain on the left shoulder. Resident 1 stated he sustained an injury while receiving care from a CNA (CNA 1) who was unfamiliar to him. Resident 1 stated, I have severe contractures, so I need a bit more help and time, but he didn't know that. I told him but he dismissed me. Resident 1 stated recalled telling the CNA 1 to be gentler but CNA 1 dismissed me and continued repositioning him forcefully. Resident 1 stated he has severe contractures and requires additional time and assistance with care, but CNA 1 did not appear to know about his condition and handled him roughly, causing pain. Resident 1 explained due to his pre-existing arthritis and chronic pain, he did not realize the severity of the injury until Friday 3/7/2025, when the pain became unbearable. Resident 1 stated he then informed the nurses who assessed him and facilitated his transfer to the hospital in which an X-rays confirmed fractures in his left shoulder. During an interview of Resident 1's roommate, Resident 2, on 3/11/25, at 10:15 AM, Resident 2 stated while he was in the room with Resident 1, he heard CNA 1 interacting with Resident 1 on multiple occasions and observed CNA 1 handling Resident 1 roughly. Resident 2 stated he could hear Resident 1 expressing discomfort during care by CNA 1 and CNA1 did not request assistance from other staff when attending to Resident 1. During an interview on 3/11/2025 at 11:25 AM, CNA 2 stated on 3/7/2025, Resident 1 was observed with bruising on the elbow that extended to the shoulder. CNA 2 stated Resident 1 informed him that Resident 1 had been rough while giving him care which he reported to the charge nurse on the same day. During an interview on 3/11/2025 at 2PM with the DON stated Resident 1 denied falling and only reported pain on the left shoulder on 3/7/25, the attending physician was notified, and the resident was transferred to the hospital for surgical evaluation. The DON stated the resident returned to the facility on the same day and was ordered to be administered pain medication and referral to the orthopedic surgeon. The DON stated he initiated the investigation on 3/7/2025 but did not interview CNA1 who matched the description that the resident reported and did not suspend the CNA1 to work since CNA1 just returned to work on today (3/11/2025). During a concurrent interview and record review 3/11/2025 at 2:30 PM with the DON indicated the Facility Reported Incident (FRI) intake (a report provided by the facility to the Department of Public Health), dated 3/10/2025 timed at 1:37 PM, indicated the facility reported to the an allegation of injury of unknown origin related to Resident 1 who reported on 3/7/2025 at 10 AM that Resident 1 had contractures, discoloration on the left upper arm and refused to be touched by the DON. The FRI report did not indicate Resident 1's report of allegation of abuse. During an interview on 3/11/2025 at 3:15 PM, with CNA 1, CNA 1 denied handling Resident 1 roughly and claimed he assisted Resident 1 multiple times. CNA 1 stated that he used a sheet to reposition the resident rather than pulling his arms and asking a staff to assist with repositioning Resident 1. CNA 1 stated he did not ask any staff to assist with repositioning Resident 1.CNA 1 stated repositioning Resident 1 with significant mobility limitations required maximum assistance. CNA 1 was unable to explain how the resident sustained visible injuries and denied hearing any complaints of pain at the time of care. During an interview on 3/11/2025 at 3:30 PM with the DON, the DON stated that CNA 1 should not have been rough with Resident 1. The DON stated that proper care protocols were not followed, which contributed to the resident's injury. A review of the investigation report dated 3/11/2025, not timed, indicated the DON went to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056322 If continuation sheet Page 3 of 4 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 056322 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave Montrose, CA 91020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few 1's room with CNA 1 without exchange of words. Then CNA 1 walked out. The DON came back and asked Resident 1 if that was the CNA. The report indicated Resident 1 confirmed that CNA1 was the staff that took care of him and was rough. DON reassured Resident of his safely. A review of facility's policy and procedure (P&P) titled Abuse-Prevention, Screening, & Training Program revised on July 2018, indicated the facility does not condone any form of resident abuse, The P&P indicated the facility conducts mandatory staff training programs during orientation, annually and as needed on recognizing abuse, to whom and when to report without fear of reprisal. The P&P indicated The facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property/and or mistreatment is more likely to occur. The P&P indicated The facility provides, and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of resident property/and/or mistreatment. A review of facility's P&P titled Abuse-Reporting & Investigations revised on May 2018, indicated To protect the health, safety, and welfare of Facility residents by ensuring that alt reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. The P&P indicated The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime; Individuals who may have information relevant to the allegation or suspected crime are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056322 If continuation sheet Page 4 of 4