Health inspection·February 12, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm 16, 2022. In addition, there was no care plan developed to address Resident 1's limitation in ROM on both upper extremities after it was identified in the MDS on July 27, 2023. 2. On February 6, 2024, at 3:31 p.m., Resident 21 was observed lying in bed with both hands flexed at the wrist and all fingers on both hands were clenched. Residents Affected - Some On February 8, 2024, Resident's 21's record was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included polyosteoarthritis (pain and stiffness affecting five or more joints). A review of Resident 21's Summary Order, dated September 29, 2022, indicated Resident 21 was on Apixiban 5 mg (milligram -unit of measurement) twice a day. A review of Resident 21's MDS, dated January 7, 2024, indicated Resident 21 had limitation in ROM on one side of the upper extremities. In further review of Resident 21's record, there was no documented evidence a care plan was developed to address Resident 21's limitation in ROM on one side of the upper extremities after it was identified on the MDS record on January 7, 2024. In addition, there was no documented evidence a care plan was developed for the use of Apixaban medication. 3. On February 6, 2024, at 10:13 a.m., Resident 22 was observed side-lying in bed with both knees flexed towards her chest. On February 8, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic (long-term) pain syndrome ( broad term that covers long-lasting pain and inflammation that can happen after an injury or a medical event). A review of Resident 22's MDS, dated October 3, 2023, and January 3, 2024, indicated Resident 22 had limitation in ROM on both lower extremities. In further review of Resident 22's record, there was no documented evidence a care plan was developed to address Resident 22's limitation in ROM on both lower extremities after it was identified on the MDS record on October 3, 2023, and January 3, 2024. 4. On February 9, 2024, at 12:04 p.m., Resident 29 was observed with the Certified Restorative Nursing Assistant (CRNA) and Licensed Vocational Nurse (LVN) 4, lying in bed with both hands flexed at the wrist and fingers clenched. In a concurrent interview with the CRNA, she stated Resident 29 was unable to extend both hands at the wrist and open all fingers. In a concurrent interview with LVN 4, she stated Resident 29 had contractures of both hands and fingers and she was not sure when the resident developed the contractures. On February 9, 2024, Resident 29's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses which included dementia (cognitive impairment). A review of Resident 29's MDS, dated June 2, 2023, indicated Resident 29 had limitations in ROM on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 2 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 one side of the upper extremity. Level of Harm - Minimal harm or potential for actual harm In further review of Resident 29's record, there was no documented evidence a care plan was developed to address Resident 29's limitation in ROM on both upper extremities and/ or when it was initially identified on the MDS record on February 15, 2018. Residents Affected - Some 5. On February 6, 2024, at 3:30 p.m., an observation and concurrent interview was conducted with Resident 151. Resident 151 was observed sitting in her wheelchair inside her room. Resident 151 was observed with both ankles extended in a downward position. Resident 151 was observed not able to flex both ankles upward. In a concurrent interview with Resident 151, she stated she had foot drop (difficulty lifting the front part of the foot) on both of her feet. On February 8, 2024, Resident 151's record was reviewed. Resident 151 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use). A review of Resident 151's History and Physical, documented by the physician, on January 22, 2024, indicated Resident 151 had weakness and bilateral (both) foot drop. In further review of Resident 151's record, there was no documented evidence a care plan was developed to address Resident 151's to bilateral foot drop after it was identified on the History and Physical on January 22, 2024. On February 9, 2024, at 4:50 p.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD). The ADON and the DSD stated all residents were to be assessed for any contractures and/or limitation with their ROM upon admission. The ADON and the DSD stated residents with contractures and/or limitations with ROM were discussed during care plan meeting quarterly. The ADON and the DSD stated there was no documentation of a comprehensive care plan was developed for Residents 1, 21, 22, 29, and 151 to address residents' limitation in ROM and/or contractures. On February 9, 2024, at 6:16 p.m. a concurrent interview and record review was conducted with the ADON and the DSD. The ADON and the DSD stated Resident 21's had an order for apixaban started on September 29, 2022. The DSD stated there should have been a care plan developed for Resident 21's use for Apixaban. The facility's policy and procedure titled Care Plans, dated April 17, 2017, was reviewed. The policy indicated, .A comprehensive care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .care plan is developed within seven (7) days of the completion of the resident assessment or within twenty-one (21) days after the resident's admission, whichever occurs first .a preliminary care plan is developed upon the resident's admission. The preliminary care plan is used only until the comprehensive care plan has been developed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 3 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for seven of seven residents (Residents 1, 16, 21, 22, 28, 29, and 151) reviewed for range of motion (ROM the full movement potential of a joint), a system or process was in place to: 1. Identify, assess, evaluate, and monitor residents with limited ROM and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to (abnormality and stiffness of the joints); and 2. Provide an appropriate care and treatment to improve, maintain, or prevent contractures and/or limitation with ROM. On February 9, 2024, at 7:20 p.m., the Administrator (ADM), the Assistant Director of Nursing (ADON), and the Director of Staff Development (DSD) were verbally notified of the Immediate Jeopardy (IJ situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility failure to identify, assess, evaluate, monitor, and provide appropriate care and treatment, for seven residents (Residents 1, 16, 21, 22, 28, 29, and 151) with limited ROM and/or contractures. These failures resulted in delayed identification of residents with limited ROM and/or contractures which delayed the provision of care and treatment for Residents 1, 16, 21, 22, 28, 29, and 151. This delayed in provision of care and treatment had placed the residents at risk for further decline in ROM and/contractures. On February 11, 2023, at 3:03 p.m., the ADM presented an acceptable plan of actions which included the following: - The seven residents identified to be affected by the deficient practice will be evaluated/screened by therapy on Monday 2/12/24, to determine if they are candidates for therapy services, or if restorative nursing (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) services are required; - The results of the screening will be communicated to the physician on Monday 2/12/24 and the facility will obtain therapy/restorative nursing orders for all residents affected by the deficient practice to identify what interventions to implement to improve, maintain, or prevent further decline in range of motion; - Care Plans were initiated and will be updated after the therapy evaluation and subsequent Physician orders for the seven residents affected by the deficient practice; to address what interventions, equipment, services, and orders are in place to improve, maintain, or prevent further decline in range of motion; - All residents in the facility were assessed by the Registered Nurse for limited range of motion and/or contractures. Additional residents were identified as having some degree of limited range of motion; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 4 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some - All residents identified as having limited range of motion and/or contractures will be evaluated/screened by Therapy on Monday 2/12/24, to determine if they are candidates for therapy services, or if restorative nursing services are required; - A range of motion assessment will be completed by a Registered Nurse and documented on all new admissions entering the facility to identify residents with limited range of motion and/or contractures. Residents identified as having limited range of motion and/or contractures will be reported to the Physician for potential therapy screening or Restorative Nursing Program; - The range of motion assessment will be completed and documented quarterly by a Registered Nurse in conjunction with the comprehensive assessment, to evaluate and monitor any progress or decline in range of motion; - The interdisciplinary team will review the quarterly range of motion assessment at Care Plan meetings and update the care plan as needed/indicated. The interdisciplinary team includes the following members: Director of Staff Development (DSD), Assistant Director of Nursing (ADON), MDS Coordinator, Behavioral Specialist, Social Services Designee (SSD), Medical Records Director, Director of Nursing (DON), Infection Preventionist (IP), and Restorative Nursing Aide (RNA); - The facility Behavioral Specialist has been designated to oversee the facility Restorative Nursing Program; - All staff involved in the revised process for identifying, assessing, evaluating, monitoring, and implementing appropriate treatment for residents with limited ROM and/or contractures will be in serviced by the Director of Staff Development on 2/10 and 2/11/24; - Monthly QAPI (Quality Assurance and Performance Improvement data driven and proactive approach to quality improvement) meetings will now include evaluations of our system and process for identifying, assessing, evaluating, and monitoring residents with limited range of motion and/or contractures as well as the treatment and services provided to improve, maintain, or prevent further decline in range of motion; - Monthly QAPI meetings will now include evaluations of our system and process for identifying, assessing, evaluating, and monitoring residents with limited range of motion and/or contractures as well as the treatment and services provided to improve, maintain, or prevent further decline in range of motion; - This will include reports from the RNAs on treatment and services provided to residents with limited range of motion and/or contractures; - This will include reports from the Restorative Nursing Supervisor (Behavioral Specialist) on the quarterly and admission Range of Motion assessments completed; - This will include ongoing tracking and data analysis of residents whose Range of Motion has improved or declined; and - The Director of Nursing will report to the Administrator and Medical Director at the QAA (Quality Assessment and Assurance) committee quarterly on the activities of the QAPI committee with regard to range of motion and contractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 5 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On February 12, 2024, at 5:50 p.m., the immediate jeopardy was removed in the presence of the ADM, the ADON, and the DSD, upon onsite verification of the implementation of the plan of actions. The facility was notified an extended survey would be conducted due to substandard quality of care issues. Findings: 1. On February 8, 2024, at 12:26 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed sitting in her wheelchair in the hallway with both hands flexed (bent) at the wrist and all fingers on both hands were clenched. Resident 1 was observed to be able to extend both hands with minimal effort but unable to open all her fingers except the right index finger. There was no adaptive device (any tool used to help people with disabilities or impairments) observed on Resident 1's bilateral hand. Resident 1 stated she used a device for both hands but only had one of them. She stated she did not receive any ROM exercises for both hands. On February 8, 2024, Resident 1's admission record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included venous insufficiency (occurs when leg veins do not allow blood to flow back up to the heart). A review of Resident 1's History and Physical, documented by the physician on October 16, 2022, indicated contractures of the left hand. In further review of Resident 1's medical record, there was no documented evidence interventions were initiated to address Resident 1's left hand contracture as identified by the physician on October 16, 2022. A review of Resident 1's Minimum Data Set (MDS an assessment tool), dated July 27, 2023, indicated the following: - Resident 1 had a BIMS (Brief Interview of Mental Status) of 7 (moderately impaired); and - Resident 1 had limitation in ROM to both upper extremities (part of the body that includes the arm, forearm, wrist and hand). In further review of Resident 1's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 1's limitation in ROM and/or contractures on both upper extremities were conducted by the facility. There was no documented evidence Resident 1's limitations in ROM on both upper extremities identified in the MDS assessment dated [DATE], were addressed for appropriate care and treatment. On February 9, 2024, at 12:08 p.m., Resident 1 was observed in the hallway with the Certified Restorative Nursing Assistant (CRNA) and Licensed Vocational Nurse (LVN) 3. Resident 1 was observed sitting on her wheelchair with a hand roll (used to prevent the fingers of the hand from being in a tight fist which could cause contracture) placed inside her right hand. There was no other device observed on Resident 1's left hand. In a concurrent interview with the CNRA, she stated Resident 1 was unable to extend both hands and fingers. She stated Resident 1 did not have an order for ROM exercises. In a concurrent interview with LVN 3, she stated Resident 1 had contractures of both hands and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 6 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 fingers. She stated she was not aware when Resident 1 developed the contractures on both hands. Level of Harm - Immediate jeopardy to resident health or safety 2. On February 6, 2024, at 3:16 p.m., a concurrent observation and interview was conducted with Resident 16. Resident 16 was observed sitting in his wheelchair inside his room. Resident 16 was observed with both hands flexed at the wrist in a downward position with all fingers clenched. There was no adaptive device in place on both hands for Resident 16. Resident 16 was able to extend the left hand at the wrist but unable to open up his fingers on the left hand. Resident 16 was unable to extend the right hand and open his fingers. Resident 16 stated that he was not receiving exercises for his left or right hand and would like to get further treatment and care. Residents Affected - Some On February 8, 2024, Resident 16's admission record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), neuralgia (nerve damage), and neuritis (inflammation of the nerve). A review of Resident 16's care plan dated October 2016, indicated, .has limited physical mobility r/t (related to) contractures of left hand .he will maintain current level of function through next review .Resident will receive ROM exercises as ordered by MD (MedicalDoctor/physician) .Encourage resident to wear hand rolls as tolerated . In further review of Resident 16's medical record, there was no documented evidence a physician order for ROM exercises and hand roll were initiated as indicated on the care plan. A review of History and Physical, documented by the physician, dated May 18, 2022, indicated Resident 16 had contractures of the left upper extremities. A review of Resident 16's MDS, dated October 8, 2022, indicated the following: - Resident 16 had a BIMS of 15 (no cognitive impairment); and - Resident 16 had limitation in ROM on one side of the upper and lower extremities (part of the body the includes the hip, thigh, knee, leg, ankle, and foot). A review of Resident 16's MDS, dated October 13, 2023, indicated Resident 16 had impairment on both side of the upper extremities and one side of the lower extremities. In further review of Resident 16's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 16's limitation in ROM on both side of the upper extremities and one side of the lower extremities was conducted by the facility. There was no documented evidence Resident 16's limitation in ROM identified on the resident's MDS assessment on October 13, 2023, was addressed for appropriate care and treatment. On February 9, 2024, at 12:08 p.m. Resident 16 was observed in the hallway with the CRNA and LVN 3. Resident 16 was observed sitting in his wheelchair with both hands flexed at the wrist in downward position with all fingers clenched. Resident 16 was able to extend the left hand at the wrist in upward motion but unable to extend fingers. Resident 16 was observed unable to extend the right hand at the wrist nor extend the fingers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 7 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In a concurrent interview with the CRNA, she stated she provided daily ROM exercises for both Resident 16's hands without a specific ROM order. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. She stated there were no instructions on which specific exercises were needed based on the status of Resident 16's ROM. In a concurrent interview with LVN 3, she stated Resident 16 had range of motion limitations on both hands since admission. 3. On February 6, 2024, at 3:31 p.m., Resident 21 was observed lying in bed with both hands flexed at the wrist and all fingers on both hands were clenched. Resident 21 was observed with a hand roll placed inside the palm of the right hand. On February 8, 2024, Resident's 21's admission record was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included polyosteoarthritis (pain and stiffness affecting five or more joints). A review of Resident 21's Order Summary Report, indicated the following: - Order Date: 9/14/2020 .ROM exercises to Right hand 5x (five times) a week as tolerated .; and - Order Date: 9/21/2020 .Administer right hand brace (a device designed to keep a specific joint or area of your body from moving too much) for 8 hours per day as tolerated one time a day for hand contractures and remove per schedule . A review of Resident 21's MDS, dated July 7, 2023, indicated Resident 21 had no limitation in ROM on both upper and lower extremities. A review of Resident 21's History and Physical, documented by the physician on July 10, 2023, indicated no limitation in ROM on both lower and upper and lower extremities. A review of Resident 21's MDS, dated January 7, 2024, indicated Resident 21 had limitation in ROM on one side of the upper extremities. A review of Resident 21's Monthly Physician Progress Notes, documented by the physician on February 5, 2024, indicated no limitation in ROM of the bilateral upper and lower extremities. In further review of Resident 21's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 21's limitation in ROM on one side of the upper extremities was conducted by the facility. On February 9, 2024, at 11:45 a.m., Resident 21 was observed in her room with the CRNA and LVN 4. Resident 21 was observed lying in bed with her lower legs flexed at the knee towards her chest. Resident 21 was observed with both hands flexed at the wrist and all fingers clenched. In a concurrent interview with the CNRA, she stated Resident 21 was unable to extend her right hand at the wrist nor open her fingers. She stated Resident 21 was able to extend and open her fingers on the left hand. She further stated Resident 21 had difficulty extending her knees on both sides. The CRNA stated Resident 21 was the only resident in the facility with an order for ROM exercises for her right hand. However, she stated she performed daily ROM exercises for both hands, and ROM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 8 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some exercises on knees without a specific order or instructions on how to perform it. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. In a concurrent interview with LVN 4, he stated Resident 21 had contractures on the right hand and fingers. LVN 4 stated Resident 21 had difficulty extending both knees and required assistance. 4. On February 6, 2024, at 10:13 a.m., Resident 22 was observed in her room, side lying in bed with both knees flexed towards her chest. On February 8, 2024, Resident 22's admission record reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic (long term) pain syndrome ( broad term that covers long-lasting pain and inflammation that can happen after an injury or a medical event). A review of Resident 22's MDS, indicated the following: - April 3, 2022; Resident 22 had no limitation in ROM on upper and lower extremities; and - July 5, 20223, October 3, 2023, and January 3, 2024; Resident 22 had limitation in ROM on both lower extremities. In further review of Resident 22's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 22's limitations in ROM on both lower extremities was conducted by the facility. There was no documented evidence Resident 22's limitations in ROM on both lower extremities identified on multiple MDS assessments (April 3, 2022; July 5, 2023; October 3, 2023; and January 3, 2024) were addressed for appropriate care and treatment. On February 9, 2024, at 9:30 a.m., Resident 22 was observed in her room with the CRNA and LVN 4. Resident 22 was observed lying in bed on her right side with both lower legs flexed at the knee towards her chest. The CRNA was observed performing passive (requires assistance from staff) ROM to both lower extremities, but resident was unable to fully extend both legs. In a concurrent interview with the CRNA, she stated she provided daily ROM exercises for Resident 22 without specific order or instructions on how to perform it. She further stated nobody had been evaluating the RNA services she provided to the residents. In a concurrent interview with LVN 4, he stated Resident 22 had limitations in ROM on both lower extremities. LVN 4 stated he was not sure how long and when resident developed limitations on both lower extremities. 5. On February 8, 2024, Resident 28's admission record was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included contractures of the right hand, hemiplegia, and hemiparesis of the right side. A review of Resident 28's care plan, dated November 1, 2016, indicated, .has right side hemiplegia and contracture of right hand and right ankle .will remain free from complication r/t (related to) hemiplegia and contracture through next review .monitor/document/report PRN (as needed) any (sic) of immobility: contractures forming or worsening .Resident will receive ROM exercises as ordered by MD . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 9 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some A review of Resident 28's MDS, dated August 6, 2023, indicated Resident 28 had limitations in ROM on one side of the upper and lower extremities. A review of Resident 28's Monthly Physician Progress Notes, documented by the physician, dated January 9, 2024, indicated Resident 28 had contractures of the right upper extremities. In further review of Resident 28's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 28's limitations in ROM on one side of upper and lower extremities was conducted by the facility. There was no documented evidence Resident 28's limitations in ROM on one side of upper and lower extremities identified on the MDS assessment was addressed for appropriate care and treatment. On February 9, 2024, at 11:50 a.m., Resident 28 was observed in her room with the CRNA and LVN 4. Resident 28 was observed lying in bed asleep. In a concurrent interview with the CRNA, she stated Resident 28 had contractures of her right hand and right ankle but was unable to provide the extent of her ROM limitations. She stated she provided daily ROM exercises for Resident 28's right hand and ankle without a specific order or instructions on how to perform it. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. In a concurrent interview with LVN 4, he stated Resident 28 had contractures of the right hand and ankle but not sure when she developed the contractures. 6. On February 9, 2024, at 12:04 p.m., Resident 29 was observed in his room with the CRNA and LVN 4. Resident 29 was observed lying in bed with both hands flexed at the wrist and fingers clenched. The CRNA was observed attempting to perform ROM exercises to both hands for Resident 29, but the resident refused. In a concurrent interview with the CRNA, she stated Resident 29 was unable to extend both hands at the wrist and open all fingers. She stated she provided ROM exercises to Resident 29 on both hands and fingers without a specific order or instructions on how to perform it. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. In a concurrent interview with LVN 3, Resident 29 had contractures of both hands and fingers and was not sure when the resident developed the contractures. On February 9, 2024, Resident 29's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses which included dementia (cognitive impairment). A review of Resident 29's History and Physical, documented by the physician on May 18, 2022, indicated no limitations in ROM on both upper extremities. A review of Resident 29's MDS, dated March 3, 2023, indicated Resident 29 had no limitations in ROM on upper and lower extremities. A review of Resident 29's MDS, dated June 2, 2023, indicated Resident 29 had limitations in ROM on one side of the upper extremity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 10 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In further review of Resident 29's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 29's limitations in ROM on both upper extremities was conducted by the facility. There was no documented evidence Resident 29's limitations in ROM on both upper extremities identified on the MDS assessment was addressed for appropriate care and treatment. 7. On February 6, 2024, at 3:30 p.m., an observation and concurrent interview was conducted with Resident 151. Resident 151 was observed sitting in her wheelchair inside her room. Resident 151 was observed with both ankles extended in downward position. Resident 151 was observed not able to flex both ankles upward. In a concurrent interview with Resident 151, she stated she had foot drop (difficulty lifting the front part of the foot) on both of her feet and would like to have therapy. She further stated she would like to walk again. She stated she did not receive any exercises and therapy for her foot drop since admission to the facility. On February 8, 2024, Resident 151's admission record was reviewed. Resident 151 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, and muscle wasting. A review of Resident 151's History and Physical, documented by the physician, on January 22, 2024, indicated Resident 151 had weakness and bilateral (both) foot drop. In further review of Resident 151's medical record, there was no documented evidence the physician addressed Resident 151's bilateral foot drop for further care and treatment. A review of the Resident 151's MDS, dated February 1, 2024, indicated the following: - Resident 151 had a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment); and - Resident 151 had limitations in ROM on both lower extremities. In further review of Resident 151's medical record, there was no documented evidence Resident 151's bilateral foot drop was addressed for appropriate care and treatment. On February 9, 2024, at 12:01 p.m. Resident 151 was observed in the hallway with the CRNA and LVN 4. Resident 151 was observed sitting in her wheelchair with both feet extended in a downward position. In a concurrent interview with the CRNA, she stated Resident 151 had bilateral foot drop since admission. She further stated Resident 151 did not have an order for any ROM exercises. In a concurrent interview with LVN 3, she stated Resident 151 had bilateral foot drop and was unable to flex both ankles upward. She further stated Resident 151 had this condition since admission. On February 9, 2024, at 4:50 p.m., a concurrent interview and record review was conducted with the ADON and the DSD. The ADON and the DSD stated all residents were to be assessed for any contractures and/or limitation with their ROM upon admission. The ADON and the DSD stated any contractures and/or limitation with ROM noted would be documented in the resident's record and referred to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 11 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0688 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some physician for further care and treatment. The ADON and the DSD stated residents with contractures and/or limitations with ROM were discussed during care plan meeting quarterly. The ADON stated any decline in the resident's ROM would be discussed at least during their weekly stand up meeting. She stated the CRNA maintains the list of residents receiving RNA services for limitations in ROM. She stated she did not provide oversight of the RNA services being provided to the residents. The ADON and the DSD stated only Resident 21 had an order for ROM exercises. However, she stated CRNA provided daily ROM exercises for other residents even without specific order or instructions on how to perform it. The ADON and the DSD stated the IDT would determine the necessary care and treatment each resident with contractures and/or with limitation with ROM would receive. The ADON and the DSD were not able to provide documentation of any ongoing assessment, evaluation, monitoring, and provision of care and treatment for the contractures and/or limitations with ROM for Residents 1, 16, 21, 22, 28, 29, and 151. The DSD stated the facility had been trying to develop a program to address resident's limitation with ROM and/or contractures for several years but it never happened. On February 12, 2024, at 9:55 a.m., an interview with the facility Medical Doctor was conducted. He stated all residents with contractures or limitation with their ROM should be documented in the resident's medical record. He stated resident with contractures or limitation with their ROM should be assessed, evaluated, and monitored regularly to ensure appropriate treatment and care was provided. He further stated routine assessment and evaluation was important to maintain or prevent further decline and/or to identify any new onset of contractures or limitation with ROM for the residents. He stated the seven residents identified were not assessed or evaluated routinely and it should have been done and documented. The facility's policy and procedure titled Restorative Nursing Policy & Procedure, dated November 04, 2016, was reviewed. The policy indicated, .Restorative Nursing Shall include nursing interventions that promotes the resident's ability to adapt and adjust to living as independently as possible. This concept activity focuses on achieving and maintain optimal physical, mental and psychological functioning .Licensed Nurse shall implement, coordinate and supervise the activities in the restorative nursing program .The restorative program has to be an integrated part of resident's plan of care with clearly measurable goals and interventions and periodically evaluated by a licensed nurse .Restorative aide's will chart weekly in residents EMR (electronic medical record) .Restorative aide will chart weekly in residents EMR .track the daily minutes .Monitor Weekly Progress .Summaries overall achievements weekly .Restorative aide supervisor must review notes on a weekly basis .resident progress or setbacks evaluated weekly .Goals of care plan must be evaluate (sic) and revised as needed .The Interdisciplinary Team (IDT) quarterly assess/evaluates the resident restorative nursing program . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 12 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the nasal cannula (a tube used to deliver oxygen through the nose) was replaced after seven days for two of two residents reviewed for oxygen use. (Residents 19 and 22). Residents Affected - Few This failure had the potential to result in deterioration of the nasal cannula which would allow infectious organisms to grow causing an infection to Residents 19 and 22. Findings: On February 5, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a lung disease that blocks the airflow and makes it difficult to breathe) and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). On February 5, 2024, at 10:05 a.m., Resident 22 was observed in bed using a nasal cannula (NC) for oxygen. The nasal cannula had no label to indicate the date when it was last changed. On February 5, 2024, at 10:08 a.m., Licensed Vocational Nurse (LVN 2) was interviewed. LVN 2 stated the nasal cannula should be changed once a week. LVN 2 confirmed there was no label indicating the date on the NC and there should be one. LVN 2 further stated she did not know when Resident 22's NC was last changed. On February 5, 2024, Resident 19's record was reviewed, Resident 19 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease and schizophrenia. On February 5, 2024, at 10:39 a.m., Resident 19 was observed in bed using a nasal cannula (NC) for oxygen. The nasal cannula had no label to indicate the date when it was last changed. On February 5, 2024, at 10:40 a.m., Certified Nursing Assistant (CNA 1) was interviewed. CNA 1 stated there was no label on the NC and the nasal cannula should be labeled on a weekly basis. On February 5, 2024, at 10:44 a.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated all nasal cannulas should be labeled with a date every Sunday night, and there should have been a date on the nasal cannula. A review of the policy and procedure titled, Oxygen Equipment, dated May 2010, was reviewed. The policy indicated, .cannulas should be replaced every 7 days or as often as necessary FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 13 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical supervision of the care of each resident by a physician and that orders for the resident's immediate care and needs were provided for seven of seven residents (Residents 1, 16, 21, 22, 28, 29, and 151 ) with limited range of motion (ROM- the full movement potential of a joint), and or contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to abnormality and stiffness of the joints). Residents Affected - Some These failures resulted in the delay in treatment and care for Residents 1, 16, 21, 22, 28, 29, and 151. Findings: 1. On February 8, 2024, at 12:26 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed sitting in her wheelchair in the hallway with both hands flexed at the wrist and all fingers on both hands were clenched. Resident 1 was observed to be able to extend both hands with minimal effort but unable to open all her fingers except the right index finger. There was no adaptive device observed on Resident 1's bilateral hands. In a concurrent interview with Resident 1, she stated she used a device for both hands but only had one of them. She stated she did not receive any ROM exercises for both hands. On February 8, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included venous insufficiency (occurs when leg veins do not allow blood to flow back up to the heart). A review of Resident 1's History and Physical, documented by the physician on October 16, 2022, indicated contractures of the left hand. In further review of Resident 1's record, there was no documented evidence interventions were initiated to address Resident 1's left hand contractures as identified by the physician on October 16, 2022. A review of Resident 1's Minimum Data Set (MDS - an assessment tool). dated July 27, 2023, indicated the following: - Resident 1 had a BIMS (Brief Interview of Mental Status) of 7 (moderately impaired); and - Resident 1 had limitation in ROM to both upper extremities. In further review of Resident 1's record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 1's limitation in ROM and/or contractures on both upper extremities was conducted by the facility. There was no documented evidence Resident 1's limitations in ROM on both upper extremities identified on July 27, 2023's MDS assessment were addressed for appropriate care and treatment. 2. On February 6, 2024, at 3:16 p.m., a concurrent observation and interview was conducted with Resident 16. Resident 16 was observed sitting in his wheelchair inside his room. Resident 16 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 14 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0710 Level of Harm - Minimal harm or potential for actual harm observed with both hands flexed at the wrist in a downward position with all fingers clenched. There was no adaptive device in place on both hands for Resident 16. Resident 16 was able to extend the left hand at the wrist but unable to open up his fingers on the left hand. Resident 16 was unable to extend the right hand and open his fingers. Resident 16 stated that he was not receiving exercises for his left or right hand and would like to get further treatment and care. Residents Affected - Some On February 8, 2024, Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), neuralgia (nerve damage) and neuritis (inflammation of the nerve). A review of Resident 16's care plan dated October 2016, indicated, .has limited physical mobility r/t (related to) contractures of left hand .he will maintain current level of function through next review .Resident will receive ROM exercises as ordered by MD (Medical Doctor/physician) .Encourage resident to wear hand rolls as tolerated . A review of History and Physical, documented by the physician, dated May 18, 2022, indicated Resident 16 had contractures of the left upper extremities. A review of Resident 16's MDS, dated October 8, 2022, indicated the following: - Resident 16 had a BIMS of 15 (no cognitive impairment); and - Resident 16 had limitation in ROM on one side of the upper and lower extremities. A review of Resident 16's MDS, dated October 13, 2023, indicated Resident 16 had impairment on both side of the upper extremities and one side of the lower extremities. In further review of Resident 16's record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 16's limitation in ROM on both side of the upper extremities and one side of the lower extremities were conducted by the facility. There was no documented evidence Resident 16's limitation in ROM for both lower and upper extremities were addressed for appropriate care and treatment. 3. On February 6, 2024, at 3:31 p.m., Resident 21 was observed lying in bed with both hands flexed at the wrist and all fingers on both hands were clenched. Resident 21 was observed with a hand roll placed inside the palm of the right hand. On February 8, 2024, Resident's 21's record was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included polyosteoarthritis (pain and stiffness affecting five or more joints). A review of Resident 21's Order Summary Report, indicated the following: - Order Date: 9/14/2020 - .ROM exercises to Right hand 5x (five times) a week as tolerated .; and -Order Date: 9/21/2020 - .Administer right hand brace for 8 hours per day as tolerated one time a day for hand contractures and remove per schedule . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 15 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0710 Level of Harm - Minimal harm or potential for actual harm A review of Resident 21's MDS, dated July 7, 2023, indicated Resident 21 had no limitation in ROM on both upper and lower extremities. A review of Resident 21's History and Physical, documented by the physician on July 10, 2023, indicated no limitation in ROM on both lower and upper and lower extremities. Residents Affected - Some A review of Resident 21's MDS, dated January 7, 2024, indicated Resident 21 had limitation in ROM on one side of the upper extremities. A review of Resident 21's Monthly Physician Progress Notes, documented by the physician on February 5, 2024, indicated no limitation in ROM of the bilateral upper and lower extremities. In further review of Resident 21's record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 21's limitation in ROM on one side of the upper extremities was conducted by the facility. There was no documented evidence Resident 21's limitation in ROM of the upper extremities was addressed for appropriate treatment and care. 4. On February 6, 2024, at 10:13 a.m., Resident 22 was observed side-lying in bed with both knees flexed towards her chest. On February 8, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic (long-term) pain syndrome (occur together and characterize a particular abnormality or condition). A review of Resident 22's MDS, indicated the following: - April 3, 2022; Resident 22 had no limitation in ROM on upper and lower extremities; and - July 5, 2023, October 3, 2023, and January 3, 2024; Resident 22 had limitation in ROM on both lower extremities. In further review of Resident 22's record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 22's limitations in ROM on both lower extremities were conducted by the facility. There was no documented evidence Resident 22's limitations in ROM on both lower extremities were addressed for appropriate care and treatment. 5. On February 8, 2024, Resident 28's record was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included contractures of the right hand, hemiplegia and hemiparesis of the right side. A review of Resident 28's care plan, dated November 1, 2016, indicated, .has right side hemiplegia and contracture of right hand and right ankle .will remain free from complication r/t hemiplegia and contracture through next review .monitor/document/report PRN (as needed) any (sic) of immobility: contractures forming or worsening .Resident will receive ROM exercises as ordered by MD . A review of Resident 28's MDS, dated August 6, 2023, indicated Resident 28 had limitations in ROM on one side of the upper and lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 16 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 28's Monthly Physician Progress Notes, documented by the physician, dated January 9, 2024, indicated Resident 28 had contractures of the right upper extremities. In further review of Resident 28's record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 28's limitations in ROM on one side of upper and lower extremities was conducted by the facility. There was no documented evidence Resident 28's limitations in ROM on one side of upper and lower extremities were addressed for appropriate care and treatment. 6. On February 9, 2024, at 12:04 p.m., Resident 29 was observed with the CRNA and LVN 4, lying in bed with both hands flexed at the wrist and fingers clenched. In a concurrent interview with the CRNA, she stated Resident 29 was unable to extend both hands at the wrist and open all fingers. In a concurrent interview with LVN 4, she stated Resident 29 had contractures of both hands and fingers and was not sure when the resident developed the contractures. On February 9, 2024, Resident 29's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses which included dementia (cognitive impairment). A review of Resident 29's History and Physical, documented by the physician on May 18, 2022, indicated no limitations in ROM on both upper extremities. A review of Resident 29's MDS, dated March 3, 2023, indicated Resident 29 had no limitations in ROM on upper and lower extremities. A review of Resident 29's MDS, dated June 2, 2023, indicated Resident 29 had limitations in ROM on one side of the upper extremity. A review of Resident 29's Monthly Physician Progress, dated February 5, 2024, indicated no limitations on both upper extremities. In further review of Resident 29's record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 29's limitations in ROM on both upper extremities was conducted by the facility. There was no documented evidence Resident 29's limitations in ROM on both upper extremities identified on MDS assessment were addressed for appropriate care and treatment. 7. On February 6, 2024, at 3:30 p.m., an observation and concurrent interview was conducted with Resident 151. Resident 151 was observed sitting in her wheelchair inside her room. Resident 151 was observed with both ankles extended in downward position. Resident 151 was observed not able to flex both ankles upward. Resident 151 stated she had foot drop (difficulty lifting the front part of the foot) on both of her feet and would like to have therapy. On February 8, 2024, Resident 151's record was reviewed. Resident 151 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, and muscle wasting (A weakening, shrinking, and loss of muscle caused by disease or lack of use). A review of Resident 151's History and Physical, documented by the physician, on January 22, 2024, indicated Resident 151 had weakness and bilateral (both) foot drop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 17 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In further review of Resident 151's record, there was no documented evidence the physician addressed Resident 151's bilateral foot drop for further care and treatment. A review of Resident 151's MDS, dated February 1, 2024, indicated the following: - Resident 151 had a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment); and - Resident 151 had limitations in ROM on both lower extremities. In further review of Resident 151's record, there was no documented evidence Resident 151's bilateral foot drop was addressed for appropriate care and treatment. On February 9, 2024, at 4:50 p.m., a concurrent interview and record review was conducted with the ADON and DSD. The ADON and the DSD stated all residents were to be assessed for any contractures and/or limitation with their ROM upon admission. The ADON and the DSD stated any contractures and/or limitations with ROM noted would be documented in the resident's record and referred to the physician for further care and treatment. The ADON and DSD stated residents with contractures and/or limitations with ROM were discussed during care plan meetings quarterly. The ADON stated any decline in the resident's ROM would be discussed at least during their weekly stand-up meetings. The ADON and the DSD was not able to provide documentation of any ongoing assessment, evaluation, monitoring, and provision of care and treatment for the contractures and/or limitations with ROM for Residents 1, 16, 21, 22, 28, 29, and 151. On February 12, 2024, at 9:55 a.m., an interview with the facility's Medical Doctor was conducted. He stated all residents with contractures or limitations with their ROM should be documented in the resident's medical record. He stated resident with contractures or limitations with their ROM should be assessed, evaluated and monitored regularly to ensure appropriate treatment and care was provided. He further stated routine assessment and evaluation was important to maintain or prevent further decline and/or to identify any new onset of contractures or limitations with ROM for the residents. He stated the seven residents identified were not assessed or evaluated routinely and it should have been done and documented. The facility's policy and procedure titled Physician Services, dated April 2018, was reviewed. The policy indicated, .The resident's attending physician participates in the resident's assessment, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. The attending physician will determine the relevance of any recommended interventions from any discipline .The physician will perform pertinent, timely medical assessments, prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 18 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for January 26, 2024, and February 1, 2024. Residents Affected - Some This failure had the potential to adversely effect the oversight and direction regarding the quality of care and quality of life, directly impacting overall health and wellbeing of all residents. Findings: During a review of the Licensed Nurse monthly schedule for the dates indicated: - On January 26, 2024, there was no RN coverage. -On February 1, 2024, there was no RN coverage. On February 5, 2024, at 3:26 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated there should have been RN coverage for January 26, 2024, and February 1, 2024. A review of the facility's policy titled, Staffing dated June 2015, had no verbiage stating, a licensed registered nurse will be onsite at least eight consecutive hours a day, 7 days a week to provide and monitor the delivery of resident care services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 19 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for three out of four residents (Residents 16, 22, and 30). The medications were signed out of the Narcotic and Hypnotic Record (NHR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. There was a total of 5 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications. Findings: The Narcotic and Hypnotic Record (NHR) for four (4) random residents receiving PRN (meaning as-needed) controlled medications were requested for review during the survey. 1. Resident 30 had a physician's order, dated September 23, 2022, for tramadol (a potent controlled medication for pain) 25 milligrams (mg, unit of measurement) by mouth every 12 hours as needed for moderate to severe pain. During a concurrent interview and record review on February 5, 2024, at 9:44 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 30's NHR for tramadol 25 mg and the MAR dated January 2024 were reviewed. The NHR for tramadol 25 mg indicated the nursing staff removed one tablet on January 31, 2024, at 9:30 a.m., from the medication cart and documented on the NHR (meaning they removed the medication from the locked controlled medication compartment in the medication cart). The MAR indicated, on January 31, 2024, for the 9:30 a.m. administration, there were no nursing staff initials in the box for Resident 30's tramadol 25 mg, to demonstrate the medication was administered. LVN 2 stated, there was no documentation on the MAR that indicated Resident 30 received the tramadol 25 mg on January 31, 2024, at 9:30 a.m. During a concurrent interview and record review on February 7, 2024, at 10:11 a.m., with the Assistant Director of Nursing (ADON), a review of Resident 30's NHR for tramadol 25 mg and the MAR dated January 2024 reflected the nursing staff signed tramadol 25 mg out of the NHR but did not document the respective administration on the MAR on January 31, 2024, at 9:30 a.m. The ADON verified this finding and acknowledged one tramadol tablet was not accounted. 2. Resident 22 had a physician's order, dated November 1, 2023, for tramadol 50 mg by mouth every 6 hours as needed for pain management moderate to severe. During a concurrent interview and record review on February 5, 2024, at 9:44 a.m., with LVN 2, Resident 22's NHR for tramadol 50 mg and the MAR dated January 2024 were reviewed. The NHR for tramadol 50 mg indicated the nursing staff removed one tablet on January 26, 2024, at 9:00 p.m., January 29, 2024, at 5:00 p.m., and January 30, 2024, at 9:00 p.m., from the medication cart and documented on the NHR (meaning they removed the medication from the locked controlled medication compartment in the medication cart). The MAR indicated, on January 26, 2024, for the 9:00 p.m., administration, January 29, 2024, for the 5:00 p.m., ,administration, and January 30, 2024, for the 9:00 p.m., administration, there were no nursing staff initials in the box for Resident 22's tramadol 50 mg, to demonstrate the medication was administered. LVN 2 stated, there was no documentation on the MAR that indicated Resident 22 received the tramadol 50 mg on January 26, 2024, at 9:00 p.m., January 29, 2024, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 20 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 5:00 p.m., and January 30, 2024, at 9:00 p.m. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on February 7, 2024 at 10:14 a.m. with the ADON, a review of Resident 22's NHR for tramadol 50 mg and the MAR dated January 2024 reflected the nursing staff signed tramadol 50 mg out of the NHR but did not document the respective administration on the MAR on January 26, 2024 at 9:00 p.m., January 29, 2024 at 5:00 p.m., and January 30, 2024 at 9:00 p.m. The ADON verified this finding and acknowledged 3 tramadol tablets were not accounted. Residents Affected - Some 3. Resident 16 had a physician's order, dated September 30, 2023, for tramadol ER (extended release 24 hour) 100 mg by mouth every 12 hours as needed for general body pain. During a concurrent interview and record review on February 5, 2024, at 12:12 p.m., with LVN 5, Resident 16's NHR for tramadol ER 100 mg and the MAR dated February 2024 were reviewed. The NHR for tramadol ER 100 mg indicated the nursing staff removed one tablet on February 3, 2024, at 9:00 a.m., from the medication cart and documented on the NHR (meaning they removed the medication from the locked controlled medication compartment in the medication cart). The MAR indicated, on February 3, 2024, for the 9:00 a.m., administration, there were no nursing staff initials in the box for Resident 16's tramadol ER 100 mg to demonstrate the medication was administered. LVN 5 stated, there was no documentation on the MAR that indicated Resident 30 received the tramadol ER 100 mg on February 3, 2024, at 9:00 a.m. During a concurrent interview and record review on February 7, 2024, at 10:19 a.m., with the ADON, a review of Resident 16's NHR for tramadol ER 100 mg and the MAR dated February 2024 reflected the nursing staff signed tramadol ER 100 mg out of the NHR but did not document the respective administration on the MAR on February 3, 2024, at 9:00 a.m. The ADON verified this finding and acknowledged one tramadol ER tablet was not accounted. The ADON stated, if controlled medications are not documented when given the concern is the risk of theft and residents not getting adequate pain control. During a review of the facility's policy and procedures (P&P), titled Controlled Substances, revised January 2018, the P&P indicated, Accurate accountability of inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters .information on the accountability record and the medication administration record (MAR). During a review of the facility's P&P, titled Administration of Drugs, dated February 2010, the P&P indicated, Medications must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etc., must be entered in the medical record and signed by the person entering the data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 21 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) when: 1. a. Resident 19 was administered lurasidone (an anti-psychotic medication for schizophrenia and bipolar depression) without adequate behavioral monitoring documented during use of lurasidone; b. Resident 21 was administered Risperdal (an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of Risperdal; c. Resident 39 was administered Zyprexa (an anti-psychotic medication for schizophrenia and bipolar disorder) and Haldol (an anti-psychotic medication for schizophrenia) without potential adverse effect monitoring documented during use of Zyprexa and Haldol. 2. Resident 21 received apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication) without a clear indication for its use; and the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of apixaban. These failures had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects for the residents. Findings 1. a. During a review of Resident 19's admission Records, dated February 8, 2024, the admission Records indicated, Resident 19 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia. During a review of Resident 19's Prescriber Order, dated June 30, 2023, the Prescriber Order indicated, Lurasidone HCL Oral Tablet 20 milligram (mg, unit of measurement) Give 0.5 tablet via PEG-Tube (tube in the stomach to provide food and medications) three times a day for schizophrenia. During a concurrent interview and record review on February 8, 2024, at 2:23 p.m., with Licensed Vocational Nurse 1/Behavioral Specialist (LVN 1/BS), Resident 19's medical records were reviewed. LVN 1/BS acknowledged Resident 19 was not monitored for behaviors during lurasidone use. LVN 1/BS stated, target behaviors should have been identified and monitored during lurasidone use. When asked why it would be important to identify and monitor behaviors, LVN 1/BS stated, To know if it [the medication] is effective. b. During a review of Resident 21's admission Records, dated February 9, 2024, the admission Records indicated, Resident 21 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes, hypertension (high blood pressure), and schizoaffective disorder. During a review of Resident 21's Prescriber Order, dated April 27, 2023, the Prescriber Order indicated, Risperdal Oral Solution Give 2 mg by mouth two times a day for Schizoaffective disorder . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 22 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on February 8, 2024, at 2:23 p.m., with LVN 1/BS, Resident 21's medical records were reviewed. LVN 1/BS acknowledged Resident 21 was not monitored for behaviors during Risperdal use. LVN 1/BS stated, target behaviors should have been identified and monitored during Risperdal use. c. During a review of Resident 39's admission Records, dated February 8, 2024, the admission Records indicated, Resident 39 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance and major depressive disorder. A review of Resident 39's medical record indicated the following physician's orders: - Zyprexa oral tablet 2.5 mg (Olanzapine) Give 2 tablet by mouth at bedtime for psychosis m/b [manifested by] agitation, dated March 23, 2023; - Haldol Injection Solution (Haloperidol Lactate) Inject 3 mg intramuscularly every 24 hours as needed for if resident refuses Remeron [medication used to treat depression], dated January 16, 2023. This order exceeded 14 days. During a concurrent interview and record review on February 8, 2024, at 2:58 p.m., with LVN 1/BS, Resident 39's medical record was reviewed. LVN 1/ BS acknowledged potential adverse effects were not monitored during Zyprexa and Haldol use. LVN 1/BS stated, adverse effects should have been monitored. During an interview on February 8, 2024, at 4:38 p.m., with the Assistant Director of Nursing (ADON), in the presence of the Director of Staff Development (DSD), the ADON stated, any antipsychotic order needs an indication for use including manifestations of behaviors or target behaviors to monitor, in order to make sure the medication is effective. During a concurrent interview and record review on February 8, 2024, at 4:55 p.m., with the ADON, in the presence of the DSD, the medical records for Residents 19, 21, and 39 were reviewed. When asked to locate documentation of behavior monitoring for the above residents, the ADON acknowledged behaviors were not monitored for the above residents. The ADON and DSD both acknowledged monitoring for behaviors should have been done for the above residents. Additionally, the ADON acknowledged Resident 39 was not monitored for potential adverse effects during Zyprexa and Haldol use and stated, it should have been monitored. The ADON verified there were no recommendations by the Consultant Pharmacist (CP) during monthly MRRs between January 1, 2023 to January 31, 2024 related to related to behavior monitoring for Residents 19 and 21 or potential adverse effect monitoring for Resident 39. During a telephone interview on February 9, 2024, at 10:41 a.m., with the CP, when asked to describe the process for antipsychotic use and monitoring, the CP stated, orders need a diagnosis, behavioral monitoring, and monitoring for adverse effects such as movement disorders. Regarding behaviors not being monitored for Residents 19 and 21 during antipsychotic use, the CP acknowledged the identified behaviors should have been monitored. When asked whether he identified and reported in the monthly MRRs regarding behavior monitoring for the above residents, the CP stated, no and acknowledged it should have been identified and reported. Additionally, the CP acknowledged potential adverse effects during Zyprexa and Haldol use should have been monitored for Resident 39. When asked if he identified and reported in the monthly MRRs regarding potential adverse effects not monitored for Resident 39 during Zyprexa and Haldol use, the CP stated, no and acknowledged it should have been identified and reported. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 23 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the CP's monthly MRRs for Resident 19, 21, and 39 from January 1, 2023 to January 31, 2024 indicated there were no recommendations from the CP related to the need for behavioral monitoring for Residents 19 and 21 during antipsychotic use, and no recommendations from the CP related to the need for potential adverse effect monitoring during use of Zyprexa and Haldol for Resident 39. During a follow-up interview on February 9, 2024, at 4:44 p.m., with the ADON, the ADON stated, the facility did not have a policy and procedure for antipsychotic behavioral monitoring. During a review of the facility's policy and procedures (P&P), titled Antipsychotic Drugs, dated June 21, 2012, the P&P indicated, Charge Nurse, Physician, and Pharmacist will monitor the response psych medication for any adverse consequences. The facility's P&P did not mention behavioral monitoring. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Zyprexa tablets, dated February 2021, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public. The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration). The Zyprexa tablet PI indicated, Most common adverse reactions .hypotension [low blood pressure], constipation, weight gain, dizziness, personality disorder, akathisia [inability to remain still] . A review of PI for Haldol injection, dated , retrieved from DailyMed. the Haldol injection PI indicated, Adverse Reactions .Warnings .Cardiovascular Effects .Stroke . Tardive Dyskinesia (irreversible, involuntary movements) .Neuroleptic Malignant Syndrome (NMS, a life-threatening neurologic emergency) .falls . 2. During a review of Resident 21's admission Records, dated February 9, 2024, the admission Records indicated, Resident 21 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes, hypertension (high blood pressure), and schizoaffective disorder. A review of Resident 21's hospital record's Emergency Provider Report, dated January 4, 2022, indicated Resident 21 was admitted to the hospital on [DATE]. A review of Resident 21's hospital record's Hospitalist Progress Note, dated February 5, 2022, indicated a medication list which included apixaban. A review of Resident 21's hospital record's Medication Administration Record, dated February 5, 2022, indicated the resident received Eliquis, Apixaban 5 milligram [mg, unit of measurement] (1 tablet) per feeding tube twice daily for maintenance treatment of DVT [deep vein thrombosis, a blood clot in a deep vein]/PE [pulmonary embolism, blockage the blood vessels that send blood to the lungs] .start 01/21/22 . During a review of Resident 21's Prescriber Order, dated September 29, 2022, the Prescriber Order indicated, Apixaban Tablet 5 mg Give 5 mg by mouth two times a day for hypervention. During a telephone interview on February 9, 2024, at 10:41 a.m., with the CP, regarding Resident 21's apixaban indication hypervention, the CP stated, I am not sure what that is. The CP acknowledged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 24 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0756 Level of Harm - Minimal harm or potential for actual harm the apixaban indication was unclear and should have been clarified. When asked if adverse effects should have been monitored during the use of apixaban, the CP stated, should have been monitored for bleeding and should have had a care plan. When asked if he identified and reported in the monthly MRRs regarding unclear apixaban indication and potential adverse effects not monitored during use of apixaban for Resident 21, the CP stated, no and acknowledged it should have been identified and reported. Residents Affected - Some A review of the CP's monthly MRRs for Resident 21 from January 1, 2023 to January 31, 2024 indicated there were no recommendations from the CP related to the unclear apixaban indication hypervention and no recommendations from the CP related to the need for potential adverse effect monitoring during use of apixaban Resident 21. During an interview on February 9, 2024, at 4:44 p.m., with the ADON, the ADON stated the facility did not have a policy and procedure for anticoagulant therapy monitoring. During a concurrent interview and record review on February 9, 2024, at 6:16 p.m., with the ADON, in the presence of the DSD, Resident 21's medical record, including the physician's order for apixaban dated September 29, 2022 was reviewed. The ADON acknowledged the apixaban indication hypervention was unclear and should have been clarified. Additionally, the ADON acknowledged Resident 21's diagnosis list did not include any diagnoses related to DVT or PE. When asked if this resident had been monitored for adverse effects such as bleeding during apixaban use, the ADON stated, No, not monitored. Both the ADON and the DSD acknowledged the resident should have been monitored for bleeding during apixaban use. The ADON verified there were no recommendations by the CP during monthly MRRs between January 1, 2023 to January 31, 2024 related to unclear apixaban indication and potential adverse effects not monitored during use of apixaban for Resident 21. A review of the PI for apixaban tablets, dated June 2021, retrieved from DailyMed, the apixaban tablet PI indicated, Indications and usage .to reduce the risk of stroke .in patients with nonvalvular [not related to heart valve] atrial fibrillation [irregular heart rhythm], for the prophylaxis [prevention] of deep vein thrombosis (DVT) .for the treatment of DVT and PE .Warnings and precautions .Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. During a review of the facility's policy and procedures (P&P), titled Medication Regimen Reviews, revised May 2019, the P&P indicated, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example .medications ordered .without clinical indication .inadequate monitoring for adverse consequences .other medication errors, including those related to documentation .An irregularity refers to the use of a medication that is inconsistent with accepted pharmaceutical services standards of practice .it may also include the use of medication without indication, without adequate monitoring . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 25 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 21) was free from unnecessary medications when Resident 21 received apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication) without a clear indication for its use; and the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of apixaban. Residents Affected - Few These failures had the potential to result in unnecessary use of medications for Resident 21 and had the potential for side effects of this medication (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. Findings During a review of Resident 21's admission Records, dated February 9, 2024, the admission Records indicated, Resident 21 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes, hypertension (high blood pressure), and schizoaffective disorder. A review of Resident 21's hospital record's Emergency Provider Report, dated January 4, 2022, indicated Resident 21 was admitted to the hospital on [DATE]. A review of Resident 21's hospital record's Hospitalist Progress Note, dated February 5, 2022, indicated a medication list which included apixaban. A review of Resident 21's hospital record's Medication Administration Record, dated February 5, 2022, indicated the resident received Eliquis, Apixaban 5 milligram [mg, unit of measurement] (1 tablet) per feeding tube twice daily for maintenance treatment of DVT [deep vein thrombosis, a blood clot in a deep vein]/PE [pulmonary embolism, blockage the blood vessels that send blood to the lungs] .start 01/21/22 . During a review of Resident 21's Prescriber Order, dated September 29, 2022, the Prescriber Order indicated, Apixaban Tablet 5 mg Give 5 mg by mouth two times a day for hypervention. During a telephone interview on February 9, 2024 at 10:41 a.m. with the Consultant Pharmacist (CP), regarding Resident 21's apixaban indication hypervention, the CP stated, I am not sure what that is. The CP acknowledged the apixaban indication was unclear and should have been clarified. When asked if adverse effects should have been monitored during the use of apixaban, the CP stated, should have been monitored for bleeding and should have had a care plan. During an interview on February 9, 2024 at 4:44 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the facility did not have a policy and procedure for anticoagulant therapy monitoring. During a concurrent interview and record review on February 9, 2024 at 6:16 p.m. with the ADON, in the presence of the Director of Staff Development (DSD), Resident 21's medical record, including the physician's order for apixaban dated September 29, 2022 was reviewed. The ADON acknowledged the apixaban indication hypervention was unclear and should have been clarified. Additionally, the ADON acknowledged Resident 21's diagnosis list did not include any diagnoses related to DVT or PE. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 26 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete asked if this resident had been monitored for adverse effects such as bleeding during apixaban use, the ADON stated, No, not monitored. Both the ADON and the DSD acknowledged the resident should have been monitored for bleeding during apixaban use. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for apixaban tablets, dated June 2021, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public. The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration.), the apixaban tablet PI indicated, Indications and usage .to reduce the risk of stroke .in patients with nonvalvular [not related to heart valve] atrial fibrillation [irregular heart rhythm], for the prophylaxis [prevention] of deep vein thrombosis (DVT) .for the treatment of DVT and PE .Warnings and precautions .Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. Event ID: Facility ID: 055361 If continuation sheet Page 27 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of five sampled residents (Residents 19, 21, and 39) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 19 was administered lurasidone (an anti-psychotic medication for schizophrenia and bipolar depression) without adequate behavioral monitoring documented during use of lurasidone; 2. Resident 21 was administered Risperdal (an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of Risperdal; 3. a. Resident 39 was administered Zyprexa (an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of Zyprexa; and without potential adverse effect monitoring documented during use of Zyprexa and Haldol (an anti-psychotic medication for schizophrenia); b. Resident 39 received an as-needed Haldol without prescriber-documented rationale and specified duration for extended use beyond 14 days. These failures had the potential to result in unnecessary use of medications for Residents 19, 21, and 39, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: 1. During a review of Resident 19's admission Records, dated February 8, 2024, the admission Records indicated, Resident 19 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia. During a review of Resident 19's Prescriber Order, dated June 30, 2023, the Prescriber Order indicated, Lurasidone HCL Oral Tablet 20 milligram (mg, unit of measurement) Give 0.5 tablet via PEG-Tube (tube in the stomach to provide food and medications) three times a day for schizophrenia. During a concurrent interview and record review on February 8, 2024, at 2:23 p.m., ,with Licensed Vocational Nurse 1/Behavioral Specialist (LVN 1/BS), Resident 19's medical records were reviewed. LVN 1/BS acknowledged Resident 19 was not monitored for behaviors during lurasidone use. LVN 1/BS stated, target behaviors should have been identified and monitored during lurasidone use. When asked why it would be important to identify and monitor behaviors, LVN 1/BS stated, To know if it [the medication] is effective. 2. During a review of Resident 21's admission Records, dated February 9, 2024, the admission Records indicated, Resident 21 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including schizoaffective disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 28 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 21's Prescriber Order, dated April 27, 2023, the Prescriber Order indicated, Risperdal Oral Solution Give 2 mg by mouth two times a day for Schizoaffective disorder . During a concurrent interview and record review on February 8, 2024, at 2:23 p.m., with LVN 1/BS, Resident 21's medical records were reviewed. LVN 1/BS acknowledged Resident 21 was not monitored for behaviors during Risperdal use. LVN 1/BS stated, target behaviors should have been identified and monitored during Risperdal use. 3. During a review of Resident 39's admission Records, dated February 8, 2024, the admission Records indicated, Resident 39 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance and major depressive disorder. A review of Resident 39's medical record indicated the following physician's orders: - Zyprexa oral tablet 2.5 mg (Olanzapine) Give 2 tablet by mouth at bedtime for psychosis m/b [manifested by] agitation, dated March 23, 2023; - Haldol Injection Solution (Haloperidol Lactate) Inject 3 mg intramuscularly every 24 hours as needed for if resident refuses Remeron [medication used to treat depression], dated January 16, 2023. This order exceeded 14 days. a. During a concurrent interview and record review on February 8, 2024, at 2:58 p.m., with LVN 1/BS, Resident 39's medical record was reviewed. LVN 1/BS acknowledged Resident 39 was not monitored for behaviors during Zyprexa use. Additionally, LVN 1/ BS acknowledged potential adverse effects were not monitored during Zyprexa and Haldol use. LVN 1/BS stated, adverse effects should have been monitored. During an interview on February 8, 2024 at 4:38 p.m. with the Assistant Director of Nursing (ADON), in the presence of the Director of Staff Development (DSD), the ADON stated, any antipsychotic order needs an indication for use including manifestations of behaviors or target behaviors to monitor, in order to make sure the medication is effective. During a concurrent interview and record review on February 8, 2024, at 4:55 p.m., with the ADON, in the presence of the DSD, the medical records for Residents 19, 21, and 39 were reviewed. When asked to locate documentation of behavior monitoring for the above residents, the ADON acknowledged behaviors were not monitored for the above residents. The ADON and DSD both acknowledged monitoring for behaviors should have been done for the above residents. Additionally, the ADON acknowledged Resident 39 was not monitored for potential adverse effects during Zyprexa and Haldol use and stated, it should have been monitored. During a telephone interview on February 9, 2024, at 10:41 a.m., with the Consultant Pharmacist (CP), when asked to describe the process for antipsychotic use and monitoring, the CP stated, orders need a diagnosis, behavioral monitoring, and monitoring for adverse effects such as movement disorders. Regarding behaviors not being monitored for Residents 19, 21, and 39 during antipsychotic use, the CP acknowledged the identified behaviors should have been monitored. Additionally, the CP acknowledged potential adverse effects during Zyprexa and Haldol use should have been monitored for Resident 39. During a follow-up interview on February 9, 2024, at 4:44 p.m., with the ADON, the ADON stated, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 29 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0758 facility did not have a policy and procedure for antipsychotic behavioral monitoring. Level of Harm - Minimal harm or potential for actual harm A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Zyprexa tablets, dated February 2021, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public. The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration). The Zyprexa tablet PI indicated, Most common adverse reactions .hypotension [low blood pressure], constipation, weight gain, dizziness, personality disorder, akathisia [inability to remain still] . Residents Affected - Some A review of PI for Haldol injection, dated , retrieved from DailyMed. the Haldol injection PI indicated, Adverse Reactions .Warnings .Cardiovascular Effects .Stroke . Tardive Dyskinesia (irreversible, involuntary movements) .Neuroleptic Malignant Syndrome (NMS, a life-threatening neurologic emergency) .falls . b. Review of Resident 39's medical record indicated there was no documented evidence to show the physician documented the rationale why the resident needed the Haldol beyond 14 days, and the end date on the as-needed Haldol order indicated indefinite. During a concurrent interview and record review on February 8, 2024 at 2:58 p.m. with LVN 1/BS, Resident 39's medical record, including the physician's order for as-needed Haldol dated January 16, 2023 and the Medication Administration Record (MAR) dated January 2023 through February 2024 were reviewed. MAR indicated, as-needed Haldol was used on January 16, 2023, January 17, 2023, January18, 2023 and January 20, 2023, and was not used after January 20, 2023. LVN 1/BS verified as-needed Haldol had been ordered over one year ago. LVN 1/BS stated, as-needed Haldol should have been reevaluated and reordered by the doctor after 14 days. LVN 1/BS was unable to locate documentation by the doctor that indicated as-needed Haldol was reevaluated after 14 days. During a concurrent interview and record review on February 8, 2024 at 5:01 p.m. with the ADON, in the presence of the DSD, Resident 39's medical record, including the physician's order for as-needed Haldol dated January 16, 2023, was reviewed. The ADON and the DSD both verified the end date on the as-needed Haldol order indicated indefinite. The ADON stated, after the 14 day limit, the doctor needed to re-evaluate to determine if it was appropriate to continue and document the rationale. The ADON stated, the end date should have been 14 days. During a telephone interview on February 9, 2024 at 10:41 a.m. with the CP, when asked to describe the process for as-needed antipsychotic use, the CP stated, as-needed antipsychotics need a 14 day evaluation with intent of discontinuing especially with non-use to make sure use is not indefinite, after 14 days can discontinue, continue, or order routine depending on doctor's evaluation of the resident. During a follow-up interview on February 9, 2024 at 6:47 p.m. with the ADON, the ADON stated, there was no documentation by the doctor in Resident 39's medical record regarding as-needed Haldol use beyond 14 days or documentation of reevaluation for continuation every 14 days. During a review of the facility's policy and procedures (P&P), titled Antipsychotic Drugs, dated June 21, 2012, the P&P indicated, Charge Nurse, Physician, and Pharmacist will monitor the response psych medication for any adverse consequences. The facility's P&P did not mention behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 30 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0758 monitoring or as-needed antipsychotic use beyond 14 days. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 31 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during the medication administration for two out of seven residents (Residents 24 and 31). The failures resulted in medications not given according to the physician's orders, had the potential for Resident 24 not receiving the full therapeutic effects the medication, and put Resident 31 at risk of receiving more medication than intended by the physician. Residents Affected - Few Findings: 1. During a medication pass observation on February 6, 2024, at 8:16 a.m., Licensed Vocational Nurse (LVN) 3 was observed preparing and administering 8 medications to Resident 24. The medications included one levothyroxine (to treat low thyroid levels) tablet. During a review of Resident 24's Prescriber Order, dated December 29, 2023, the Prescriber Order indicated, Levothyroxine sodium oral tablet Give 75 micrograms (mcg, unit of measurement) by mouth one time a day for a condition with low thyroid hormone levels in the morning before breakfast. During a concurrent interview and record review on February 6, 2024, at 9:50 a.m.,, with LVN 3, Resident 24's Medication Administration Record (MAR) dated February 6, 2024 and physician's order for levothyroxine tablet dated December 29, 2023 were reviewed. LVN 3 verified the MAR indicated levothyroxine was given after breakfast on February 6, 2024 at 8 a.m. LVN 3 stated, [Resident 24's] breakfast tray came 6:45 a.m., [Resident 24] ate around 7 [a.m.], [Resident 24] should have had this [medication] before breakfast. LVN 3 added, Would need to talk to doctor to change order to be given at a time before breakfast .currently scheduled for 8 a.m. LVN 3 stated, the it is important to give levothyroxine before breakfast in order for the medication to be absorbed. During a concurrent interview and record review on February 7, 2024, at 10:37 a.m., with the Assistant Director of Nursing (ADON), in the presence of the Director of Staff Development (DSD), Resident 24's MAR dated February 6, 2024 and physician's order for levothyroxine tablet dated December 29, 2023 were reviewed. The ADON verified the MAR indicated levothyroxine was given after breakfast on February 6, 2024 instead of before breakfast as indicated on the physician's order. The ADON stated, the expectation is for nurses to review the order and contact the doctor for clarification to change the administration time of levothyroxine to be scheduled before breakfast. The ADON stated, If levothyroxine is not given before breakfast, the medication might not get absorbed, and the Resident might not get the full therapeutic effect of the medication. During a telephone interview on February 9, 2024, at 10:41 a.m., with the Consultant Pharmacist (CP), the CP stated, levothyroxine should be given on an empty stomach to enhance absorption. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for levothyroxine tablets, dated January 2023, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public. The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration. The levothyroxine tablet PI indicated, Administer once daily, preferably on an empty stomach, one-half to one hour before breakfast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 32 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During a medication pass observation on February 6, 2024, at 8:43 a.m., LVN 3 was observed preparing and administering 4 medications to Resident 31. The medications included two Tylenol (to treat pain) tablets. During a review of Resident 31's Prescriber Order, dated January 22, 2024, the Prescriber Order indicated, Tylenol (brand name for acetaminophen) Oral Tablet 325 milligram (mg, unit of measurement) Give 325 mg by mouth every 12 hours as needed for pain management NTE [not to exceed] 3 grams (gm, unit of measurement) from all sources of APAP [acetaminophen]. During a concurrent interview and record review on February 6, 2024, at 10:00 a.m., with LVN 3, Resident 31's MAR dated February 6, 2024 and physician's order for Tylenol tablet dated January 22, 2024 were reviewed. LVN 3 stated, [Resident 31] Should be [given] one tablet but I gave two . During a concurrent interview and record review on February 7, 2024, at 10:40 a.m., with the ADON, in the presence of the DSD, Resident 31's MAR dated February 6, 2024 and physician's order for Tylenol tablet dated January 22, 2024 were reviewed. The ADON verified the Tylenol order indicated one tablet and stated, the expectation is for the nurse to Check the 5 rights, and one of the 5 rights is to give the right dose. [nurse] should have given one tablet, instead of two tablets. The ADON added, If given more Tylenol than ordered, the resident might get over medicated which can lead to liver side effects. During a telephone interview on February 9, 2024, at 10:41 a.m., with the CP, regarding Resident 31 being administered two tablets of Tylenol rather than one tablet as ordered, the CP stated, If a medication is not given as ordered, the concern is the nurse did not properly give the medication and was not reading the order. During a review of the facility's policy and procedures (P&P) titled, Administration of Drugs, dated February 2010, the P&P indicated, .the physician's order must be verified before the medication is administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 33 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 ensure storage, preparation, and distribution of food were in accordance with professional standards for food service safety, when: Residents Affected - Some 1. Food items inside the kitchen refrigerator were not labeled accordingly; 2. Cooking utensil was not in good repair and/or condition; 3. Food containers were not stored properly from a clean environment; and 4. A Dietary Aide did not perform hand hygiene in between tasks. These failures had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 47 residents who consumed food from the kitchen out of a facility census of 48 residents. Findings: On February 5, 2023, starting at 9:20 a.m., an observation of the facility kitchen and concurrent interview with the Dietary Service Director (DSD/CDM) was conducted. The following were observed: a. There were four turkey sandwiches stored inside a plastic bag in the refrigerator that were unlabeled and undated. In a concurrent interview, the DSD/CDM stated the four turkey sandwiches inside a plastic bag found in the refrigerator were unlabeled and undated. He stated the plastic bag containing the four turkey sandwiches should have been labeled and dated. b. There was one rubber spatula stored in the drawer located in the preparation/tray line table that was cracked and chipped. In a concurrent interview, the DSD/CDM stated the rubber spatula should not be chipped and/ or cracked as it can harbor bacteria and could cause cross-contamination. c. Three metal food containers and two plastic bins stored on an uncovered shelf, underneath the dishwashing sink, readily available for use. In a concurrent interview, the DSD/CDM stated the three metal food containers and two plastic bins that were stored under the dishwashing sink were clean and readily available for use. He stated the dishwashing sink is used for washing the used/dirty pots and pans. He stated the clean food containers should not be placed under the sink and should be placed in a clean environment that protects them from splashes and contamination. On February 5, 2024, at 3:40 p.m., an observation and concurrent interview with Dietary Aide (DA) was conducted. DA was observed in the kitchen wearing gloves preparing a food tray with clean napkins (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 34 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 and utensils at a preparation table. Then, DA was observed to walked to another preparation table and grabbed the red sanitizer bucket (a bucket containing a solution to disinfect dirty surfaces) where he dipped a solution test strips (to test the solution for proper concentration). After DA completed testing the solution from the red sanitizer bucket, DA continued with prepping the food tray at the preparation table without performing hand hygiene or changing his gloves in between tasks. Residents Affected - Some In a concurrent interview with DA, he stated he was preparing the food tray with clean napkins and utensil for the residents. He stated he should have washed his hands and changed gloves after testing the solution from the red sanitizer bucket before he continued with prepping the food tray for residents. On February 6, 2024, at 9:52 a.m., an interview with the Registered Dietitian (RD) was conducted. RD stated the four preprepared turkey sandwiches that were found inside the kitchen refrigerator should have been labeled and dated accordingly. She stated the rubber spatula that were cracked and chipped should have been discarded as it can harbor bacteria and cause food-borne illnesses to residents. She stated the metal food containers and plastic bins stored on an uncovered shelf underneath the dishwashing sink should have been stored in a location free from dust or splashes to prevent cross-contamination. Lastly, she stated the DA should have washed his hands and changed gloves after handling the red sanitizing bucket before he continued with preparing the food tray for residents. According to the Food Code, published by the United States Food & Drug Administration, dated 2022, .refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES .Cleaned EQUIPMENT and UTENSILS .Shall be store: .Where they are not exposed to splash, dust, or other contamination .UTENSILS shall be maintained in a state of repair or condition .or shall be discarded . The facility's policy and procedure titled Handling Clean Equipment and Utensil, dated 2019, was reviewed. The policy indicated, .Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination . The facility's policy and procedure titled Hand Washing, dated 2019, was reviewed. The policy indicated, .Employee will wash hands as frequently as needed throughout the day using proper hand washing procedure .when to wash hands .after handling soiled equipment or utensils .after engaging in other activities that contaminate the hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 35 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 ensure a Quality Assurance Performance Improvement (QAPI- group of staff working in the facility that helps the facility to self-identify issues, plan to correct, and improve the lives of the residents in nursing home) program was developed to identify, assess, evaluate, and monitor residents with limitations in Range of Motion (ROM- the full movement potential of a joint ) and/or contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to abnormality and stiffness of the joints). In addition, there were no preventive measures in place to provide appropriate care and treatment to improve, maintain or prevent limitations with ROM and/or contractures for residents who were at risk. (See findings under F688). Residents Affected - Some This failure resulted in the delay and treatment for residents identified with limitation with ROM and or contractures and had the potential to cause all other residents residing in facility to not achieve their highest physical, mental, and psychosocial well-being. Findings: On February 12, 2024, at 3:03 p.m., an interview with the Administrator (ADM) was conducted. The ADM stated he is the Governing Body (individual responsible to establish and implement policies regarding the management and operations of the facility) for the facility. The ADM further stated, prior to immediate jeopardy (IJ) identified on February 9, 2024, there was no quality-of-care and/or preventative measures in place to identify, asses, evaluate and/or monitor residents with limited range of motion (ROM - measure of joint functionality and flexibility) and/or Contractures (fixed tightening of muscle, tendons, ligaments, or skin). The facility's policy and procedure titled Quality Assurance and Performance Improvement (QAPI) plan, dated April 26, 2018, was reviewed. The policy indicated, .Our purpose is to provide excellent quality resident care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident outcomes and perceptions of patient care .Our facility has a Performance Improvement Program which systematically monitors, analyzes and improves its performance to improve resident outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care and services and cost .We will identify areas of improvement and rank them by factors such as prevalence, risk, cost, relevance, responsiveness, feasibility, and continuity .Our focus will also be on how we can create innovative best practices while making sure resident's autonomy is maintained .The Administrator is responsible and accountable for developing, leading, and closely monitoring the QAPI Program . According to CMS (Centers for Medicare and Medicaid Services) Nursing Home Quality Initiatives, dated August 29, 2017, Nursing home QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents, families, and all nursing home caregivers in practical and creative problem-solving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 36 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 implement and maintain infection control procedures when the facility staff failed to clean and disinfect a shared glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions during observation for one resident (Resident 1). Residents Affected - Few The failure had the potential for the development and the spread of infection. Findings: During a review of Resident 1's admission Records, dated February 7, 2024, the admission Records indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes. During a review of Resident 1's Prescriber Order, dated December 20, 2022, the Prescriber Order indicated, Novolog (brand name for Insulin Aspart) Solution 100 units/milliliter (ml, unit of measurement) per sliding scale subcutaneously (under the skin) four times a day for DM (diabetes) 2 . During a medication pass observation on February 6, 2024, at 11:08 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 was observed using a shared glucometer to check Resident 1's concentration of blood glucose without cleaning or disinfecting the glucometer before and after use of the glucometer. During an interview on February 6, 2024, at 2:59 p.m., with LVN 5, LVN 5 stated, [The] Glucometer is used for anyone with [blood glucose] check on insulin for the hall, each cart has own glucometer. When asked to describe the process for cleaning and disinfecting a shared glucometer, LVN 5 stated, I need to disinfect [the glucometer] with sanitizing wipe 'purple top' before use, and after .every time. LVN 5 added, I did not do that earlier .I forgot. When asked to describe the importance of proper cleaning and disinfecting of shared glucometers between residents, LVN 5 stated, For infection control. If not followed we can cause cross contamination, spreading germs. During an interview on February 7, 2024, at 10:07 a.m., with the Assistant Director of Nursing (ADON), in the presence of the Director of Staff Development (DSD), when asked to describe the process for cleaning and disinfecting of shared glucometers, the ADON stated, nurses are expected to clean and disinfect glucometers with Sani Wipes [in] purple top [container] between residents before and after each use. She said, not cleaning and disinfecting glucometers can spread infections. During a review of the facility's policy and procedures (P&P), titled Decontaminating Equipment, dated August 3, 2017, the P&P indicated, Reusable resident care equipment/instruments/devices will be maintained and decontaminated according to the manufacturer's instructions to prevent resident to resident transmission of infections .Reusable resident care equipment will be decontaminated between residents according to manufacturer's instructions .Nursing will decontaminate equipment .between use by different residents . According to the online publication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration by the Centers for Disease Control and Prevention (CDC), dated March 2, 2011, it indicated, If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 37 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, Cleaning Procedure .clean and disinfect the meter [glucometer] between patient tests . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 38 of 39 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to ensure the required 80 square feet was met for 6 of 25 resident bedrooms (Rooms 1,9,11,12,14 and 26). Residents Affected - Some This failure had the potential to negatively affect the quality of life of the resident. Findings: On February 5, 2024, at 9:00 a.m., the Administrator (ADM) was interviewed regarding the room sizes for resident Rooms 1, 9, 11, 12, 14 and 26. He stated the rooms did not meet the space requirement of at least 80 square feet in the above listed bedrooms. Rooms 1, 9, 11, 12, 14, and 26 had been set up as two-bed bedrooms. The facility document titled, Client Accommodations Analysis, dated February 12, 2024, was provided by the ADM. The document indicated the rooms set up as two-bed bedrooms measured 143 square feet or 71.5 square feet per resident (143/2 = 71.5). During the survey dates of February 5, 6, 7, 8, 9, and 12, the above listed rooms were observed at different times of the day. All care and services provided to the residents residing in the listed rooms were able to be conducted without restrictions. Residents who were able to be interviewed stated they were comfortable in the space provided. Health record reviews did not indicate the health and safety of the residents residing in these rooms were compromised, based on the room measurements. The facility requested a continued waiver for Rooms 1, 9, 11, 12, 14, and 26. Approval of the waiver was recommended. Granting this waiver will not adversely affect the residents health and safety and is in accordance with the special needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055361 If continuation sheet Page 39 of 39