Health inspection·June 9, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few baseline condition (what was considered normal for the resident). The DON did not provide an answer. The DON then stated there should be an oral/dental assessment done during the comprehensive admission assessment. At 10:20 A.M., the medical record director (MRD) joined the interview and reviewed Resident 1 ' s clinical record. The MRD stated Resident 1 did not have a comprehensive assessment done upon admission [DATE]). The MRD stated there was no documentation of any dental or oral nursing assessments done for Resident 1 during the resident ' s stay in the facility. The DON stated Resident 1 should have had an oral and dental assessment performed by the LN upon admission. The DON stated, Assessment drives care plan, and that Resident 1 should have had a written care plan that addressed her oral and dental needs based on the nursing assessment. 2. A review of Resident 5 ' s admission Record indicated the resident was admitted to the facility on [DATE]. On 5/24/23 at 12:40 P.M., an observation and interview was conducted with Resident 5 inside the resident ' s room. Resident 5 stated she was sick a couple months ago and facility staff accidentally threw away her bottom denture. Resident 5 stated a replacement should be available to her within a month. Resident 5 was observed wearing a full upper denture and no lower denture was present. On 5/24/23 at 2:40 P.M., a joint interview and record review was conducted with the DON and MRD. The DON and MRD stated there was no written plan of care that addressed the resident ' s dental and oral care needs. The DON stated there should have been an oral and dental care plan developed for Resident 5. The DON acknowledged the written dental and oral care plan should have also been developed to address Resident 5 ' s missing bottom denture. A review of the facility ' s policy titled Routine Dental Care revised April 2007, indicated, .1. The nursing care staff will conduct ongoing oral health assessments to assure that each resident receives adequate oral hygiene A review of the facility's policy titled admission Assessment and Follow Up: Role of the Nurse revised September 2012, indicated, .The purpose of this procedure is to gather information about the resident's physical .condition upon admission for the purposes of managing the resident, initiating the care plan, .8. Conduct a physical assessment, including the following systems: .c. Teeth and gums A review of the facility ' s policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . 3. Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .describes the services that are to be furnished FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely dental services and referral for outside care and treatment for one of three residents (Resident 1). In addition, the facility failed to provide clinical oversight of the social services department to ensure that dental services were being provided. Residents Affected - Few As a result, Resident 1 had experienced tooth pain which lasted for over five months, developed infection of teeth, and was unable to eat the food she enjoyed. Findings: A review of Resident 1 's admission Record dated 5/8/23, indicated the resident had been admitted to the facility on [DATE] with diagnoses to include end stage heart failure and was receiving palliative care/hospice (comfort care). On 5/4/23 at 2:15 P.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated she had tooth pain that had lasted for months and sometimes the pain kept her up at night and she could not sleep. Resident 1 stated, The pain just drives you crazy. Resident 1 stated when the pain got so bad, she had one tooth pulled and it was infected, and she had to go on antibiotics. Resident 1 stated she needed to have all her remaining teeth pulled and to be fitted for dentures. Resident 1 stated when she or her family asked about getting her dental concerns addressed, the facility ' s social worker (SW) 1 would tell her, We ' re working on it. Resident 1 stated the facility was not following up on her dental care needs. Resident 1 further stated she had trouble chewing food because of the pain and missed being able to eat the food she enjoyed. Resident 1 stated she was tired of having soup. On 5/4/23 at 2:45 P.M., an interview was conducted with SW 1. SW 1 stated it was her job to coordinate routine and emergency dental services for the residents and to arrange and facilitate residents ' dental appointments and transportation. SW 1 stated she had been working on Resident 1 ' s dental concerns and referrals and that it had been complicated having to coordinate with hospice, different providers, and insurance issues. A review of Resident 1 ' s clinical record was conducted. Resident 1 ' s progress notes indicated: 10/29/22 Resident 1 complained of having a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 11/2/22 Resident 1 was complained of having a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 11/15/22 Resident 1 complained of having a toothache. 11/16/22 Resident 1 complained of having a toothache. 1/16/23 Resident 1 ' s daughter met with SW 1 to discuss dental surgery scheduling. The resident ' s daughter reported the dentist provided a referral. SW 1 asked the resident ' s daughter to provide a copy of the referral. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 1/18/23 SW 1 informed Resident 1 that nursing was working on scheduling her appointment for hospital dental work. Level of Harm - Actual harm Residents Affected - Few 1/23/23 SW 1 spoke to resident ' s daughter and reminded nursing to schedule appointment for (oral surgeon). 1/25/23 Licensed nurse (LN) called oral surgeon ' s office and was informed they did not accept Resident 1 ' s Medicaid (a state funded program) insurance. SW 1 was notified. 2/8/23 SW 1 received call from oral surgeon ' s office that they do not accept Medicaid. SW 1 would follow up with Resident 1 and her family. 2/10/23 Resident 1 verbalized having a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/17/23 SW 1 discussed Resident 1 ' s dental appointment concerns with the resident ' s family and that the referred oral surgeon did not accept Medicaid. SW 1 and family to find a Medicaid provider. 2/25/23 Resident 1 had a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/26/23 Resident 1 had a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/27/23 Resident 1 had a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/27/23 Resident 1 went out for a dental appointment. 3/14/23 (Hospice note) Resident 1 reported having tooth pain. 3/20/23 Resident on antibiotics for tooth infection. 3/23/23 Resident complained of tooth pain. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 3/26/23 .Pt [patient] continues to report severe tooth pain. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 4/3/23 SW 1 documented she was unaware Resident 1 ' s family scheduled an outside dental appointment for 4/6/23. On 5/5/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated she was familiar with Resident 1 and that the resident had been in her assigned section since February 2023. LN 1 stated Resident 1 frequently complained of toothache and mouth pain. LN 1 stated Resident 1 usually complained of tooth pain around lunchtime and that it hurt to chew the food. LN 1 stated Resident 1 received routine Percocet (a strong pain medication that was not prescribed for the resident ' s dental concerns) around lunchtime, and she did not always document when the resident complained of having tooth pain around that time because a routine pain medication was being given. LN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 Level of Harm - Actual harm Residents Affected - Few stated she did not know what to do when the resident complained about tooth pain because that was considered a dental issue. LN 1 then stated that pain was a nursing concern, and that the resident ' s physician should have been notified. LN 1 stated Resident 1 ' s tooth pain was not a routine dental concern but required emergency dental care. LN 1 stated pain could indicate infection and that needed to be taken care of promptly. LN 1 reviewed Resident 1 ' s progress notes from October 2022 through current date of interview. LN 1 stated when Resident 1 complained of having tooth pain, there was no documentation that the LN had notified the physician or facility dentist. LN 1 further stated Resident 1 had complained of tooth pain since October 2022 and, It ' s been going on too long . LN 1 stated, Toothaches hurt. I wouldn ' t want to go more than a week without having something done about it. On 5/5/23 at 11:16 A.M., a telephone interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated Resident 1 first complained of a toothache in October 2022 and that she had reported it to SW 1 and a LN whose name she could not recall. FM 1 stated Resident 1 frequently complained of tooth pain and that it kept her up at night and was throbbing. FM 1 stated the family had to bring soup in for Resident 1 to eat because she could not chew regular food without having a lot of pain. FM 1 stated Resident 1 had not been able to enjoy the food she liked to eat because it hurt to bite down. FM 1 stated it bothered her hearing how often Resident 1 was experiencing tooth pain and the Facility ' s lack of action. FM 1 stated Resident 1 was not a complainer, and it was significant when the resident kept talking to her about the pain. FM 1 stated she began emailing SW 1 in November 2022 in an effort to get Resident 1 ' s dental needs addressed. FM 1 stated Resident 1 ' s jaw and cheek area had been swollen starting around February 2023. FM 1 stated Resident 1 had a toothache for months until the business office manager (BOM) had seen one of her emails to SW 1 in February 2023 when SW 1 was not at work. FM 1 stated the BOM made an appointment to have Resident 1 seen by a dentist in a matter of one day. FM 1 stated she did not understand why SW 1 had been unable to address Resident 1 ' s dental needs for months. FM 1 stated she had accompanied Resident 1 on that February dental appointment where an infected tooth had been extracted. FM 1 stated Resident 1 needed all her remaining teeth extracted. FM 1 stated she had a difficult time getting the facility to assist with this. FM 1 stated due to lack of facility assistance, she had set up an outside appointment for Resident 1 to have all remaining teeth extracted (for 4/6/23). FM 1 stated when Resident 1 got to the appointment they would not see a patient in a gurney. FM 1 stated Resident 1 had to be sent back to the facility unseen by the outside provider. FM 1 stated this was frustrating. FM 1 stated this had gone on for too long and Resident 1 should not have been in pain and discomfort like this for months. A review of email correspondence between FM 1 and SW 1 was reviewed and indicated: 11/7/22, from FM 1, .Can you please provide an update on when the dentist will visit [Resident 1]? She is waiting on a new partial denture and is also experiencing a lot of pain in one of her back teeth right now. 11/8/22, from SW 1, .The dentist will here [sic] tomorrow before 4 pm, and [Resident 1] is first on her list. 1/17/23, from FM 1, .The doctor for [Resident 1], said that you would schedule the appointment at the hospital for her teeth to be taken care of, and the procedure has already been approved. Is there any word on the date yet? 2/22/23, from FM 1, .I have been emailing you [SW 1] since 11/7/2022 trying to get the procedure done for [Resident 1 ' s] teeth. I just received a call from her and she stated she was up all night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 Level of Harm - Actual harm with a terrible toothache. It ' s not right that she has had this same problem for months and nothing has been done. It would be appreciated if someone at [facility name] could arrange the care she needs as soon as possible as she is in a lot of pain and has been waiting a very long time. (The BOM was included in this email) Residents Affected - Few 2/23/23, from FM 1 to the BOM, .Aren ' t these arrangements for dental care for [Resident 1] a matter that the facility would take care of? I emailed [SW 1] several weeks ago and her last email indicated that she was looking into it. 2/23/23, from the BOM, . Usually yes, the social worker at the facility handles these .Is any dentist that can get her in the soonest preferred? 2/23/23, from FM 1, . The soonest appointment is definitely preferred. [Resident 1] should not have to be up all night with a toothache. Because the matter was not addressed four months ago when I sent the first email, it has now become urgent. 4/26/23, from FM 1, .I just had a 40 minute phone conversation with [state sponsored insurance]. They stated that [facility name] should have a dentist that comes in and takes care of the dental needs of long term patients .If your onsite dentist is unable to provide the care [Resident 1] needs they are required .to provide a referral to someone who can help .The neglect of [Resident 1 ' s] oral care has gone on for an unacceptable period of time. 4/26/23, from SW 1, .Yes the facility has an in house dentist [dentist name], she has seen and evaluated [Resident 1]. [Dentist name] also provided the referral for the hospital doctor for the tooth extractions needed which you are aware . 4/26/23, from FM 1, .I am unaware that any referral that [dentist name] may have provided 6 or more months ago. If she did so, why didn ' t [facility] follow up and be sure [Resident 1] got to an appointment at the hospital for the necessary treatment? Last Saturday one of her teeth actually fell out while she was eating breakfast and she is in a lot of pain every day. Full dentures need to be made for [Resident 1] and an oral surgeon located to remove all her teeth immediately. This has now become an urgent matter. On 5/5/23 at 3:30 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated a resident ' s pain, including mouth or dental pain, needed to be addressed right away. The DSD stated Resident 1 ' s tooth pain could have been from infection and that was not appropriate for the social services department to manage. The DSD stated dental pain was considered an emergency dental need and nursing should have been involved. The DSD reviewed Resident 1's progress notes and stated Resident 1 should have been seen right away back in October 2022 when the resident first reported the toothache. A review of Resident 1 ' s Dental Referral Form dated 12/1/22, indicated the facility ' s dentist (DDS) 1 had referred the resident to be seen and treated by an oral surgeon for extraction of all remaining upper teeth and teeth numbered 24, 19, and 18 (specific location of the teeth). The referral also indicated the resident was bedbound and required a gurney. A review of Resident 1 ' s hospice physician ' s letter dated 3/16/23, indicated, .[Resident 1] needs dental treatment in a hospital to extract her teeth. Please work with the family to get this procedure scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 Level of Harm - Actual harm Residents Affected - Few On 5/23/23 at 3:22 P.M., a telephone interview was conducted with FM 1. FM 1 stated she was unaware DDS 1 had made a referral for Resident 1 to be seen by an oral surgeon on 12/1/22. FM 1 stated they had been given the run around by the facility about insurance issues for Resident 1 ' s needed dental treatment. FM 1 stated the facility did not discuss any problems with Resident 1 ' s Medicaid that would impede the resident ' s access to treatment. FM 1 stated Resident 1 ' s family had the ability to pay cash for the resident ' s needed dental treatment. FM 1 stated the facility did not discuss a cash option to Resident 1 and her family in order to expedite the resident ' s treatment. FM 1 stated the whole thing had taken too long and Resident 1 was in pain. FM 1 stated, She [Resident 1] should be eating tacos by now, and be able to enjoy her favorite food. On 5/24/23 at 8:36 A.M., an interview was conducted with certified nursing assistant (CNA) 2. CNA 2 stated she regularly took care of Resident 1. CNA 2 stated Resident 1 complained about her teeth and mouth pain nearly every meal. CNA 2 stated she did not know how long Resident 1 had been complaining of tooth pain because it had been going on for so long. CNA 2 stated Resident 1 would tell her that it hurt to chew and that she had to eat soup. CNA 2 stated Resident 1 was tired of eating soup. On 5/24/23 at 8:45 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 had complained for a long time about having tooth pain. On 5/24/23 at 8:50 A.M., a joint interview and record review was conducted with the BOM. The BOM stated he recalled being part of a bedside interdisciplinary team (IDT, different facility disciplines) meeting for Resident 1 sometime back in December 2022 or January 2023. The BOM stated during the IDT, Resident 1 ' s family discussed the resident ' s dental concerns and SW 1 had told them she was working on it. The BOM stated arranging dental care, making resident dental appointments, and arranging transportation to dental appointments was managed by the social services department or SW 1. The BOM stated sometime after the IDT, he started getting added to FM 1 ' s emails to SW 1. The BOM stated he had noticed FM 1 complaining about Resident 1 ' s dental pain and It was a lot of pain complaints. The BOM stated when he asked SW 1 about it, she would say she had taken care of the issue. The BOM stated in February 2023, when SW 1 was out, he got involved because Resident 1 ' s issue seemed urgent. The BOM stated it was not his job responsibility but, When a resident ' s in pain, you have to handle it. The BOM stated he had no difficulty and did not encounter any insurance issues and was able to schedule an emergency dental appointment a day or two later for Resident 1. The BOM reviewed resident 1 ' s Dental Referral Form dated 12/1/22 and stated, It shouldn ' t have taken so long to set something up. The BOM stated a reasonable amount of time to coordinate with Resident 1 ' s hospice, insurance, outside providers, and establish an appointment should take no longer than a week. The BOM stated if there were issues with Resident 1 ' s Medicaid, there should have been a care conference and the option to pay cash should have been discussed. The BOM stated toothaches were painful and needed to be handled right away. A review of Resident 1 ' s emergency dental visit documentation dated 5/16/23, indicated, .patient was seen at our office for dental emergency treatment on 02/27/23. Emergency exam 4 periapical [around the root of the tooth] x-rays taken. Patient presented with severe pain lower left posterior # 18. Extensive root and furcation [where tooth root splits into separate parts] decay, tooth is unsalvageable and needs to be extracted . Full thickness flap raised, bone removed DB [debridement, the removal of dead or infected tissue] .I prescribed Flagyl [antibiotic] . Patient was seen again on 3/13/23 for comprehensive oral examination, unsalvageable remaining upper and lower teeth recommend removal of all teeth and fabricate full upper denture and full lower denture. I referred patient to oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 surgeon [name omitted], to remove all teeth Level of Harm - Actual harm On 5/24/23 at 10:52 A.M., a joint interview and record review was conducted with DDS 1 by telephone. DDS 1 stated she provided care and treatment to residents in nursing homes. DDS 1 stated she did not perform root canals or complicated extractions and that she would refer the resident to an outside provider if she was unable to provide the care herself inside the nursing home. DDS 1 stated Resident 1 had a partial denture on top that had been attached to broken teeth. DDS 1 stated she examined Resident 1 in August and September 2022, and the resident had no complaints of pain at that time. DDS 1 stated she saw Resident 1 in November 2022, and the resident complained of pain but declined more invasive treatment at that time. DDS 1 stated she saw Resident 1 again on 12/1/22, and the resident had required a root canal and/or extractions and she made the referral on 12/1/22 for the resident to be seen by an oral surgeon. DDS 1 stated the referral had been given to facility staff. DDS 1 stated Resident 1 required treatment in a hospital type of setting due to her medical condition. DDS 1 stated it was her expectation that the facility assisted Resident 1 in making the referral appointment since the resident was not able to do that on her own. Residents Affected - Few Resident 1 ' s emergency dental visit documentation dated 5/16/23, was reviewed with DDS 1. DDS 1 stated Resident 1 ' s #18 tooth had become infected at the root and the dentist removed the infected tissue and prescribed an antibiotic to prevent the spread of the infection. DDS 1 stated the facility had not contacted her about Resident 1 after the 12/1/22 visit and she had been unaware of Resident 1 ' s 2/27/23 outside emergency dental visit. DDS 1 stated she had assumed the referral she made for Resident 1 on 12/1/22 had been carried out timely. DDS 1 stated she had a routine visit to other residents in facility on 4/12/23 and stopped by to see Resident 1. DDS 1 stated Resident 1 refused to be seen because her family was setting up a hospital appointment for her teeth. DDS 1 stated she had been surprised in April 2023, to learn her referral made on 12/1/22 for Resident 1 ' s oral surgery had not been acted upon. DDS 1 stated her referral for Resident 1 on 12/1/22 had not been carried out in a timely manner. DDS 1 stated if the 12/1/22 referral had been carried out the same month it was made, Resident 1 could have avoided further pain and tooth infection. DDS 1 stated one or two weeks was too long to have dental pain. On 5/24/23 at 12:02 P.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated she still had tooth pain and described it as being an on and off pain. Resident 1 stated she was still waiting to have her teeth extracted at the hospital. Resident 1 stated she was told SW 1 no longer worked at the facility. Resident 1 stated, So there ' s no one to take care of it until there ' s a new social worker. Can you believe that? Resident 1 stated, It ' s aggravating. Resident 1 stated lunch was on the way, and it was probably soup again. Resident 1 stated she missed being able to eat tacos. On 5/24/23 at 2:15 P.M., an interview was conducted with the director of nursing (DON). The medical records director (MRD) was also present. The DON stated she had been In the dark about Resident 1 ' s dental issues. The DON stated she was unaware Resident 1 had a dental treatment referral from 12/1/22 that had not been carried out. The DON stated nursing should have been involved with Resident 1 ' s dental concerns since there was pain involved. The DON stated dental pain was a clinical concern and it should not have been managed by the social services department. The DON stated it was her expectation for dental referrals to be carried out in a timely manner. The DON stated while social services could make appointments and arrange transportation, there should have been clinical oversight to ensure dental care and treatment was being provided to the residents. On 5/24/23 at 4:55 P.M., an interview was conducted with the administrator (ADM). The DON and MRD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0790 Level of Harm - Actual harm Residents Affected - Few were also present. Resident 1 ' s ongoing dental pain, tooth infection, and not being able to enjoy preferred foods, were discussed with the ADM. The ADM stated he had been unaware of Resident 1 ' s dental concerns and that SW 1 had been let go due to work performance issues. The ADM stated, Moving forward there would be clinical oversight to make sure residents ' dental needs were followed up on. The ADM stated for Resident 1 ' s dental issues to have been unresolved for over five months was weird and it should not have gone on for so long without being resolved. A review of Resident 1 ' s hospital progress note dated 6/2/23, indicated the resident had received oral surgery.[Resident 1] with jaw pain and dental pain . Multiple abscessed teeth [pockets of pus caused by infection], status post surgical extraction teeth . debridement maxilla mandible [upper and lower jaw] by [surgeon ' s name] A review of the facility ' s policy titled Emergency Dental Care revised April 2007, indicated, . 1. Emergency dental care is available on a 24-hour basis. 2. Should a resident need emergency dental care, the dental consultant shall be notified so that arrangements for the emergency care can be made. 3. Social Services shall contact the consultant dentist to set up the appointment . 4. Emergency dental services include services needed to treat an acute episode of acute pain in teeth, gums, or palate [roof of the mouth]; or otherwise damaged teeth, or any problem of the oral cavity appropriately treated by a dentist that requires immediate attention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three residents ' (Residents 1, 2, and 3) medical records were complete when documentation of assessments, care, and/or treatment from providers outside the facility were not available for review. As a result, the residents ' medical records were incomplete and did not provide necessary information related to the residents ' condition. Findings: 1. A review of Resident 1 ' s admission Record dated 5/8/23, indicated the resident was admitted to the facility on [DATE] with diagnoses to include end stage heart failure and was receiving palliative care (comfort care). On 5/4/23 at 2:15 P.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated she had tooth pain that lasted for months and that she had to go on antibiotics for a tooth infection. Resident 1 stated she had been seen by the dentist but did not recall the dates of each visit. A review of Resident 1 ' s progress notes dated, 2/27/23 indicated, the resident went to a dental appointment. There was no documentation in Resident 1 ' s clinical record of what transpired during the resident ' s dental visit. A review of Resident 1's progress notes dated, 3/9/23 indicated, the resident had a dental appointment on 3/13/23. A review of Resident 1 ' s social services note dated, 3/16/23 indicated, the resident ' s daughter was inquiring about the antibiotics ordered by the dentist after the resident's treatment. On 5/5/23 at 2 P.M., a joint interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated there was no documentation of what occurred during the resident ' s dental visit on 2/27/23. LN 1 stated there was no documentation Resident 1 had gone to a dental appointment on 3/13/23. LN 1 stated she recalled Resident 1 going out for a dental appointment around that timeframe and returning with an order for antibiotics. LN 1 stated the antibiotic order from the dentist Got lost in the shuffle and had not been followed up on promptly. LN 1 stated it had taken a few days to find the antibiotic order. LN 1 stated the documentation in Resident 1 ' s clinical record was unclear as to whether or not the resident went out for dental appointment, what treatment was provided during the appointment, what follow up care was needed after the appointment, and what the resident ' s antibiotics were for, after the dental visit. On 5/5/23 at 3:30 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated Resident 1 had been seen by the facility ' s dental provider. The DSD stated there was no documentation in the resident ' s clinical record of dental exams that were done by the facility ' s dental provider. The DSD stated that documentation should be part of the resident ' s medical record to know what was being done and if further care or treatment was needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 1 ' s dental documentation (received via email on 5/9/23) indicated the resident had been evaluated and/or treated by the facility dentist on 8/3/22, 9/16/22, 11/9/22, 12/1/22, and 4/27/23. A review of Resident 1 ' s emergency dental visit documentation dated, 5/16/23 (received 5/16/23 and provided by Resident 1 ' s family member via email) indicated, the resident had been evaluated by an outside dental provider on 2/27/23, had an infected tooth extracted, and had been ordered antibiotics. The documentation further indicated Resident 1 was evaluated again on 3/13/23 and provided a referral for oral surgery. A review of the facility ' s contract with the facility ' s dental provider titled Dental Services Agreement, dated 5/17/23, indicated, .The provider agrees to .provide accurate and timely documentation . of services provided to residents of the facility 2. A review of Resident 2 ' s admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer ' s disease (progressive disease that destroys memory and other important mental functions). The California Department of Public Health received a complaint alleging Resident 2 had a fractured right humerus (upper arm) and medical care had not been provided to the resident in a timely manner. An onsite visit was conducted on 5/4/23 to investigate the complaint. A review of Resident 2 ' s x-ray results dated, 4/25/23 indicated, .Proximal right humeral fracture A review of Resident 2 ' s progress notes dated, 4/25/23 indicated, the resident sustained a witnessed fall on 4/24/23, sustained a right humerus fracture, and was sent out to the hospital for further evaluation. A review of Resident 2 ' s interdisciplinary team (IDT) notes dated 4/26/23, indicated the resident had returned to the facility with no right humerus fracture. There was no documentation in Resident 2 ' s clinical record of the hospital visit on 4/25/23 and evaluation whether or not there was a right humeral fracture. On 5/4/23 at 4:10 P.M., an observation was conducted and an interview was attempted with Resident 2 inside the resident ' s room. Resident 2 was wiggling around in bed and fidgeting with her adult brief. Resident 2 mumbled and was not cognitively able to participate in an interview. Resident 2 was not observed to have either arm in a cast or sling. On 5/5/23 at 11:55 A.M., a joint interview and record review was conducted with the DSD. The DSD stated the information the facility received, indicating the resident did not have a right humeral fracture, was provided to the licensed nurse (LN) in report (communication usually over the phone between the nurse at the facility and the nurse at the hospital to provide verbal information about the resident ' s visit). The DSD stated nurse report had the possibility of being wrong. The DSD stated the IDT should have verified the accuracy of the nurse report by reviewing the hospital documentation. The DSD stated there was discharge paperwork sent with Resident 2 from the hospital visit dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4/25/23 that had insufficient information regarding the resident ' s treatment and did not indicate if a humeral fracture had been evaluated and ruled out. The DSD stated the hospital documentation the facility had was for a lay person who was cognitively able to understand their medical condition and what had happened at the hospital. The DSD stated the hospital documentation provided to the facility was not appropriate for a receiving facility that was going to continue providing care to the resident. The DSD stated Resident 2 had been sent out to the hospital on 4/25/23 to be evaluated for a right humeral fracture. The DSD stated based on the hospital documentation it was unclear if the resident had a fracture or not. The DSD stated clear documentation of a resident ' s medical evaluation and care and treatment provided should have been acquired within 24-hours of care/treatment being rendered. On 5/5/23 at 2 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated it was unclear whether or not the resident had a right humeral fracture. LN 1 stated the hospital discharge documents dated 4/25/23, were not suitable for continuity of care. LN 1 stated the IDT should have requested appropriate hospital documentation to verify whether or not Resident 2 had a fracture. LN 1 stated nurses ' report had the potential to be incorrect. LN 1 stated statements given during the nurse report should be supported with appropriate documentation. A review of Resident 2 ' s hospital documentation (received via email on 5/9/23) and dated 4/25/23 indicated, XR [x-ray] humerus right .Impression 1. Old healed fracture of the proximal right humerus. No acute osseous [bone] abnormality 3. A review of Resident 3 ' s admission Record indicated, the resident was admitted to the facility on [DATE] with diagnosis to include dementia (condition characterized by impairment of memory and judgement). The California Department of Public Health received a facility reported incident alleging Resident 3 called Resident 4 a racial slur and then was hit on the head by Resident 4. An onsite visit was conducted to investigate the allegation on 5/24/23. A review of Resident 3 ' s progress notes dated, 5/9/23 indicated, Resident 3 alleged he was hit by Resident 4 and that the LN had observed purplish discoloration to Resident 3 ' s outer earlobe. Resident 3 was to be sent out to the hospital for evaluation. A review of Resident 3 ' s IDT note dated 5/11/23 indicated, the resident was evaluated at the hospital on 5/10/23 and the imaging of the resident ' s head revealed no fractures or internal bleeding. There was no documentation in Resident 3 ' s clinical record of the hospital evaluation and imaging results done on 5/10/23. On 5/24/23 at 10:30 A.M., an interview was conducted with the medical records director (MRD). The MRD stated there were difficulties getting documentation from outside providers. The MRD stated that documentation of care and treatment from outside providers and hospital visits should be part of the resident ' s clinical record. The MRD stated the documentation, if it was missing or insufficient, should be followed up on within 24 to 48 hours of care/treatment being provided. On 5/24/23 at 2:15 P.M., a joint interview and record review was conducted with the director of nursing (DON). The MRD was also present. The DON stated the documentation of the resident ' s hospital evaluation on 5/10/23 was not in the resident ' s clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DON stated the evaluations, care, and/or treatment provided to residents from all providers should be in the residents ' medical records. On 5/24/23 at 4:55 P.M., an interview was conducted with the administrator (ADM). The DON and MRD were also present. The ADM stated all documentation of care and treatment rendered to residents should have been in the residents ' medical records. A review of the facility ' s policy titled Charting and Documentation revised July 2017, indicated, .All services provided to the resident . shall be documented in the resident ' s medical record .7. Documentation of procedures and treatments will include care- specific details, including: .c. The assessment data FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their action plans to identify and correct a deficiency that was identified during a complaint investigation when the facility's Plan of Correction (POC) dated 7/7/23 with compliance date 7/9/23, was not followed. Residents Affected - Few As a result, the facility remained in non-compliance and this had the potential to affect the quality of care for all the residents in the facility. (Cross Reference F842) Findings: 1. Resident 1's orthopedic (musculoskeletal) appointment documentation was not available in the resident's clinical record and Resident 2's optometry (eye) appointment did not take place as it was indicated in the resident's clinical record. 2. The facility's audits were inaccurate and incomplete and did not identify these discrepancies. 3. The facility's QAPI (Quality Assurance Program Improvement) committee did not thoroughly review the POC audits, determine its compliance rate, and take needed action to ensure substantial compliance. A review of the facility's POC dated 7/7/23, indicated, .Medical Records Director (MRD) will request and ensure post-outside ancillary service provider documentation is received, reviewed by the DON [director of nursing] then uploaded into resident medical record .DON or DSD [director of staff development] will perform 5 random weekly audits x 4 [weeks] of the MRD to verify that outside ancillary service provider documentation is uploaded into the medical record . Findings of the audit will be reviewed during monthly QAPI meeting for the next 90 days until 100% compliance is achieved. Audit findings will be discussed by the Administrator and DON and any needed action will be taken to ensure substantial compliance . Date of compliance 7/9/23. A review of the facility's document titled [facility name] F-842 Checklist to Ensure Completion of POC Week 1 Weekly Review of 5 Residents Appointment Documentation Audit Period: 7/9/23 through 7/14/23, indicated, Resident 1 had been seen by orthopedics on 7/12/23 and Documentation filed into EHR [electronic health record] was marked Y (yes) and the audit had been completed by the director of nursing (DON). On 8/2/23 at 11:35 A.M., a joint interview and record review was conducted with the DON. Resident 1's clinical record was reviewed. The DON stated there was no documentation from Resident 1's orthopedic appointment on 7/12/23 in the resident's EHR. On 8/2/23 at 12:15 P.M., a joint interview and record review was conducted with the DON. The DON stated the facility's 7/9/23 through 7/14/23 audit of Resident 1's orthopedic documentation from 7/12/23 had been inaccurate and had failed to capture the discrepancy. The DON stated, It got missed. The DON acknowledged the facility's POC with compliance date 7/9/23, had not been fully implemented. A review of the facility's document titled [facility name] F-842 Checklist to Ensure Completion of POC Week 2 Weekly Review of 5 Residents Appointment Documentation Audit Period: 7/15/23 through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 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 055078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7/21/23, indicated, Resident 2 had an appointment for optometry and the rest of the audit categories for Resident 2 were blank. On 8/2/23 at 3:57 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 2's clinical record and [facility name] F-842 Checklist to Ensure Completion of POC Week 2 Weekly Review of 5 Residents Appointment Documentation Audit Period: 7/15/23 through 7/21/23, and stated she was still trying to figure out if Resident 2 had gone to an optometry appointment on 7/18/23 and where the documentation for the appointment was at. The DON stated the audit for 7/15/23 through 7/21/23 was not complete yet. The DON stated the issue with Resident 2's appointment should have been figured out and the audit should have been complete at the time the audit was done. The DON stated the facility had a QAPI meeting on 7/27/23. The DON stated the POC audits were not thoroughly discussed or reviewed in the QAPI meeting, the facility's compliance was not determined, and corrections for discrepancies had not been identified or addressed. On 8/2/23 at 5:01 P.M., a joint interview was conducted with the facility's administrator (ADM), DON, and chief nursing officer. The ADM stated it was his expectation that POC audits were accurate and complete. The ADM acknowledged the POC audits were not thoroughly reviewed during the facility's QAPI meeting held on 7/27/23 and the facility's compliance had not been determined. A review of the facility titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership revised March 2020, indicated, . e. Focuses on problems and opportunities that reflect processes, functions and services provided to the residents . 4. The responsibilities of the QAPI Committee are to: a. Collect and analyze performance indicator data and other information; b. Identify, evaluate, monitor and improve facility systems and processes . 5. b. Choosing and implementing tools that best capture and measure data about the chosen indicators; c. Appropriately interpreting data within the context of standards of care, benchmarks, targets and the strengths and challenges of the facility; and d. Communicating the information gathered and their interpretation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055078 If continuation sheet Page 15 of 15