Health inspection·July 15, 2024

F689 Residents Affected - Few (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the facility's policy regarding safety and supervision of residents was implemented, when one of the four sampled residents (Resident 1) was not supervised during lunchtime, which potentially resulted to a change of condition leading to Resident 1 being transferred to a general acute hospital for evaluation and treatment. This failure had the potential to place a clinically compromised resident (Resident 1) at risk for aspirating when resident was not supervised by the staff during mealtime. Findings: During a review of Resident 1's History and Physical H&P) dated February 3, 2023, the H&P indicated that Resident 1 had a diagnosis that included paraplegia (loss of muscle function and senses of the legs and lower body), seizure (a sudden uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movement[uncontrollable shaking, with muscles contracting and relaxing repeatedly, however, some have mild symptoms without shaking] feelings, and level of consciousness), and dysphagia (difficulty of swallowing). During a review of facility provided document titled SBAR (stands for situation, background, appearance, review and notify.) communication form and progress notes for RNs/LVNS/LPNs (registered nurses, licensed vocational nurses & licensed practical nurses). It indicated Resident 1 was found unresponsive and necessitated initiation of a code blue (a hospital code for an emergency that requires resuscitation - the process of reviving a patient that lacks breathing or pulse). was initiated, and subsequently transferred to an acute hospital. During a telephone interview on July 3, 2024, at 4:03 PM, with the Speech Therapist (ST -a profession that work to prevent , assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders ) ST 1 stated Resident 1 did not require assistance with feeding at that time, but needed someone to be with him to ensure that he was following aspiration precautions (swallowing problems like choking while or after eating). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056444 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 056444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Extended Care Hospital of Montclair 9620 Fremont Ave Montclair, CA 91763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm During a telephone interview on July 8, 2024, at 4:03 PM, with the Director of Nursing (DON 1), DON 1 stated that she could not find any notes regarding Resident 1's condition during lunchtime or whether staff supervised or assisted the resident during lunch on August 29, 2023. However, DON 1 stated that she found a document in the nurse's notes dated August 28, 2023, the day before Resident 1 was transferred, indicating that Resident 1 was supervised while eating. Residents Affected - Few During a review of the ST 1's evaluation and treatment plan for Resident 1 covering the certification period from August 16,2023 through September 10, 2023, it was noted that ST 1 recommended distant supervision and close supervision during mealtime. The document also mentioned that the resident was at risk for aspiration due to documented physical impairment. During a review of Resident 1's care plan for activities of daily living (ADL - activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking using the toilet, and eating.) dated February 2, 2023, the care plan indicated that Resident 1 required supervision while eating. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated May 2015, the P&P indicted, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056444 If continuation sheet Page 2 of 2