Health inspection·May 5, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 399 was initiated on 5/2/23. Resident 399 was admitted to the facility on [DATE]. Review of Resident 399's MDS dated [DATE], showed Resident 399 was cognitively intact and required total assistance from one to two staff members for ADL care. Residents Affected - Few On 5/2/23 at 0925 hours, CNA 5 was summoned to go to Residents 14 and 399's room. CNA 5 verified the call light and water pitchers were not within Residents 14 and 399's reach. CNA 5 was observed assisting Resident 14 with water, and another staff came to assist Resident 399. 3. On 5/5/23 at 0930 hours, Resident 9 was observed in bed, with the head of the bed elevated. Resident 9's call light cord was observed clipped on the left side of the bed, and the call light button was observed hanging on the side of the bed. Resident 9's bed remote control was observed at the foot of the bed. Resident 9 asked for help to reposition herself. When asked if she could reach her call light button, Resident 9 attempted to reach her call light but could not reach it. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 had severe cognitive impairment and required extensive assistance from one to two staff members for ADL care. On 5/5/23 at 0935 hours, CNA 1 was summoned to go to Residents 9's room. CNA 1 verified the call light and the bed remote control were not within Resident 9's reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 2 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to clearly identify the current medical intervention status for one of 12 final sampled residents (Resident 20). In addition, a copy of Resident 20's advance directive was not available in the resident's medical record. These failures had the potential to not provide the proper care in accordance with the resident's treatment wishes. Findings: Medical record review for Resident 20 was initiated on 5/2/23. Resident 20 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 20's MDS dated [DATE], showed Resident 20 had moderate cognitive impairment. Review of Resident 20's Order Summary Report showed a physician's order dated 5/4/22, for DNR with comfort measures only. Review of the POLST dated 4/4/23, showed, Do Not Attempt Resuscitation/DNR (Allow Natural Death) and Selective Treatment were checked. Further review of the POLST, under Section D, showed the advance directive was not available. Review of the Social Services Assessment/ Evaluation V2 dated 3/20/23, showed Resident 20 did not have an advance directive. However, the Additional Information section showed Resident 20 had an existing advance healthcare directive but the resident's representative did not have access to it at this time. Review of the the resident's plan of care did not show Resident 20's code status and medical interventions were addressed. On 5/3/23 at 1536 hours, an interview and concurrent medical record review was conducted with RN 1. When asked about the different medical interventions mentioned in the POLST, RN 1 stated, full treatment meant to do everything such as intubation and ventilation; selective treatment meant to do non-invasive procedures such as IV treatments; while comfort-focused treatment meant to only provide comfort measures only such as oxygen, and no IV treatments and no intubation. RN 1 verified Resident 20's medical interventions on the POLST form was not reflected in the physician's order. When asked about the facility's process regarding the resident's advance directive, RN 1 stated upon admission, the resident was asked if there was an advance directive, and a copy was requested if the resident had an advance directive. RN 1 stated the case manager or the social services department would follow-up with the resident or the representative for a copy of the advance directive. On 5/3/23 at 1545 hours, an interview and concurrent medical record review for Resident 20 was conducted with the SSD. When asked about the existence of Resident 20's advance healthcare directive, the SSD stated she did a follow-up call and spoke with Resident 20's representative. The SSD stated she was told by the resident's representative that Resident 20 did not have an advance directive, so they would go by the POLST. When asked if there was any documentation of the follow-up call she made to the resident's representative, the SSD only showed her personal notes but did not mention anything about Resident 20's advance directives. The SSD verified there was no documentation in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 3 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0578 Level of Harm - Minimal harm or potential for actual harm 20's medical records regarding her follow-up call with Resident 20's representative. The SSD verified Resident 20's POLST showed her advance healthcare directive was not available. The SSD also verified the medical interventions on the POLST form did not match the physician's order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 4 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop the plan of care to reflect the individual care needs for one of 12 final sampled residents (Resident 349). * The established care plan problems did not include the individualized the non-pharmacological interventions to address Resident 349's specific behaviors. This failure posed the risk of not providing the appropriate and individualized care to the resident. Findings: Review of the facility's P&P titled Care and Treatment for Psychotropic Drug Use revised August 2017 showed upon initial comprehensive assessment the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotoropic medications. These residents will be referred to the facility's Psychotropic Drug Reviw Committe and/or the psychiatrist to ensure the care plan shows individualized, person-centered care approaches to manage behavior with non-pharmacological interventions. Medication record review for Resident 349 was initiated on 5/4/23. Resident 349 was admitted on [DATE]. Review of Resident 349's H&P examination dated 4/22/23, showed Resident 349 had no capacity to understand and make decisions. Review of Resident 349's plan of care showed the care plan problems were developed to address the following: - the use of the antipsychotic medication manifested by yelling out without apparent reason - the use of the antianxiety medication manifested by yelling out - the use of the antidepressant medication manifested by crying However, the non-pharmacological interventions included in these care plan problems were the same as follows: back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quite environment, encourage to express feelings, take to activities, and provide reassurance. On 5/5/23 at 1105 hours, an interview was conducted with the DON. The DON was asked regarding Resident 349's individualized care plan for the use of the psychotropic medications. The DON stated the care plan for Resident 349 was individualized. The DON was asked regarding the non-pharmacological interventions being generic and same for the resident's behaviors and use of antianxiety, antipsychotic, and antidepressant medications. The DON stated she would need to figure out how to make those changes on the PCC (Point Click Care) to reflect the resident's individual interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 5 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 12 final sampled residents (Resident 7). The facility failed to provide activities for Resident 7 which met her identified interests. This had the potential for Resident 7 to experience feelings of social isolation and frustration. Residents Affected - Few Findings: On 5/2/23 at 0847 hours, during the initial tour of the facility, Resident 7 was observed awake and lying in bed. There was no TV, or any in-room sensory stimulation observed. On 5/3/23 at 0742, 1015, 1033, 1604, and 1623 hours, Resident 7 was observed awake and lying in bed. Resident 7 was observed starring at the ceiling and curtain and touching her face. There was no TV, or any in-room sensory stimulation observed. On 5/3/23 at 1055 hours, an observation of Resident 7 and concurrent interview was conducted with CNA 1. When asked about the resident's activities, CNA 1 stated Resident 7 sometimes went to the dining room/activities room to eat, if not, Resident 7 stayed in the room. CNA 1 stated when Resident 7 was in bed, sometimes the TV was on; and sometimes, the resident did not do anything. Resident 7 was observed in bed, awake, and starring at the curtain. There was no TV, or any in-room sensory stimulation observed. CNA 1 verified there were no activities provided to the resident. When asked about Resident 7's TV, CNA 1 stated the TV was behind the door. On 5/3/23 at 1623 hours, an observation of Resident 7 and concurrent interview was conducted with RN 1. Resident 7 was observed in bed, awake, and touching her face. There was no TV, or any in-room sensory stimulation observed. RN 1 verified no activities were provided to Resident 7. Medical record review for Resident 7 was initiated on 5/2/23. Resident 7 was admitted to the facility on [DATE]. Review of the MDS 1/31/23, showed Resident 7 could make self usually understood and understand others, and was dependent on the staff for all ADL care. Review of the Activity - Quarterly Evaluation dated 5/3/23, showed Resident 7 needed encouragement to participate in social programs, special events, music, religious services, trivia, senior topics, exercise, movies, televisions, and arts/crafts. Review of the Activities Care Plan revised date 7/2/22, showed Resident 7 needed respectful encouragement and significant interactive motivation from staff participation in 1:1 room visits and group activities. Review of the Daily Activity Participation Documentation for April and May 2023 showed there was no activity provided from 4/1 to 4/7/23, and the week was marked with x and the word quarterly' was written. The documentation showed Resident 7 was mostly provided with socializing which was documented as a or active, and Resident 7 was also provided with a newspaper/daily chronicle which was documented as active and p or passive. The documentation also showed Resident 7 was provided with movies/TV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 6 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 4/8, 4/9, 4/10, 4/11, 4/12, 4/25, 4/29, 4/30, 5/1, 5/2, and 5/3/23, which was documented as active and passive. On 5/4/23 at 1019 hours, an interview and concurrent medical record review for Resident 7 was conducted with the Activities Director. When asked what activities were provided to Resident 7, the Activities Director stated the activity staff provided group activities for Resident 7 daily. The Activities Director stated when Resident 7 was in bed, the activity staff also turned the TV on for her and also provided music for her by turning the TV of her roommate which provided the music for her and her roommate. When asked whether Resident 7 could participate in the activities actively or passively as documented in the activity participation record, the Activities Director verified Resident 7 was documented to be actively and passively participating with the activities, but it was the Activity Assistant who filled out the form. On 5/4/23 at 1033 hours, an observation of Resident 7's TV and concurrent interview was conducted with the Activities Director. The Activities Director was asked to show where Resident 7's TV was, the Activities Director showed the TV which was behind the door. When asked to turn the TV on, the Activities Director could not find the remote control for Resident 7's TV and tried to use the other residents' TV remote controls. The Activities Director acknowledged she could not turn the TV on. On 5/4/23 at 1048 hours, an interview and concurrent medical record was conducted with the Activities Assistant. When asked what activities were provided to Resident 7, the Activities Assistant stated she went to the resident's room daily to give the daily chronicle paper. When asked if Resident 7 went to the activity room daily, the Activities Assistant stated she would only bring Resident 7 to the activities room when the CNAs got her up in the wheelchair. The Activities Assistant stated if Resident 7 stayed in bed, she was provided with TV or music. The Activities Assistant stated she turned the TV on alternately with her roommate. When asked about the daily activity participation documentation, the Activities Assistant verified she filled out the form. When asked what active or passive meant, the Activities Assistant stated she documented active when the resident was sort of participating such as when she responded, and passive when they did the activities for the resident. The Activities Assistant acknowledged she should have documented passive with the activities provided for Resident 7. On 5/4/23 at 1059 hours, a follow-up interview was conducted with the Activities Director. The Activities Director stated she called the Maintenance Director to check Resident 7's TV. The Activities Director stated they found out Resident 7's TV was unplugged and the TV remote control was underneath the resident's belongings inside the drawer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 7 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 medical record review, the facility failed to ensure the physician's order was obtained for a contact precaution for one nonsampled resident (Resident 500). This failure created the risk of not providing the appropriate and consistent care for Resident 500. Residents Affected - Few Findings: On 5/2/23 at 0815 hours, during the initial tour of the facility, a sign showing respiratory, droplet, and contact precaution with instructions to perform hand washing, wear gloves, gown, N95 mask, and face shield was posted at the entry of Resident 500's room. On 5/2/23 at 0818 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 500 was on contact isolation for cough. On 5/2/23 at 0920 hours, an interview was conducted with Resident 500. Resident 500 stated he was on isolation for cough and had not been out of the room. Medical record review for Resident 500 was initiated on 5/2/23. Resident 500 was admitted to the facility on [DATE]. Review of Resident 500's H&P examination dated 4/14/23, showed Resident 500 had the capacity to understand and make decisions. Review of Resident 500's Order Summary Report with active orders as of 4/13/23 and 5/1/23, failed to show an order for contact precaution. Review of Resident 500's MAR for April 2023 and May 2023 failed to show an order for contact precaution. Review of Resident 500's Progress Notes, under the Change of Condition Note, dated 4/27/23 at 0355 and 0930 hours, showed Resident 500 was noted with cough and chest congestion. Further review of Resident 500's medical record showed Resident 500 was negative for COVID-19. On 5/5/23 at 0811 hours, a concurrent interview and medical record review was conducted with the DSD/IP. The DSD/IP stated Resident 500 was on contact precaution for cough. The DSD/IP acknowledged Resident 500 did not have an order for contact precaution and stated it may or may not have an order for quarantine. The DSD/IP further stated it was an extra precaution for the facility to quarantine Resident 500. On 5/5/23 at 1136 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the above findings and stated there should have an order for contact precaution. The DON further stated it was the practice of the facility to have an order for contact precaution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 8 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 12 final sampled residents (Resident 398) remained free of accident hazards. * The facility failed to provide Resident 398 with the bilateral floor mats and bolster pillow, and failed to keep the bed in the lowest position as per the physician's orders and care plan. This failure had the potential for the resident to fall and sustain injuries. Findings: On 5/2/23 at 0849 hours, during the initial tour of the facility, Resident 398 was observed awake and lying in bed. A gray floor pad was on the left side of the bed, and the bed was observed not in the lowest position. Medical record review was initiated on 5/2/23. Resident 398 was admitted to the facility on [DATE]. Review of Resident 398's Order Summary Report showed the following physician's orders dated 10/21/22: - to use bilateral floor pads for safety; - to use bolster pillows to bilateral side of the bed to assist patient in repositioning while in bed; and - to keep bed at the lowest position when in bed except during meals and ADL care. Review of Resident 398's plan of care showed a care plan problem addressing falls. The interventions included bilateral floor pads, bilateral bolster pillow, and continued with the use of the low bed. Review of the SBAR Communication Form dated 3/3/23, showed Resident 398 was found on the floor mat next to bed. Review of the LN-Fall Risk Evaluation dated 4/12/23, showed Resident 398 was a high risk for fall. On 5/3/23 at 0810 and 1032 hours, Resident 398 was observed asleep in bed. A gray floor pad was observed on the left side of the bed, no bolster pillows observed, and the bed was approximately two feet high, not in the lowest position. On 5/3/23 at 1614 hours, an observation for Resident 398 and concurrent interview and medical record review was conducted with RN 1. Resident 398 was observed asleep in bed. A gray floor pad was observed on the left side of the bed, no bolster pillows observed, and the bed was approximately two feet high, not in the lowest position. RN 1 verified the findings. RN 1 was observed putting the bed to the lowest position. On 5/4/23 at 1010 hours, an observation for Resident 398 and concurrent interview was conducted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 9 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 with LVN 1. A gray floor pad was observed on the right side of the bed. LVN 1 verified the findings. LVN 1 stated he was not sure why Resident 398 only had the floor pad on one side. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 10 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/2/23 at 0905 hours, Resident 25 was observed on GT feeding of Glucerna (a type of feeding formula) 1.2 Cal at the rate of 55 ml/hours. The ST was observed at bedside. Medical record review for Resident 25 was initiated on 5/2/23. Resident 25 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 25's Order Summary Report showed the following physician's orders: - dated 3/13/23, to administer Glucerna 1.2 via GT at 55 ml/hour; - dated 3/3/23, to administer acetaminophen (pain medication) 325 mg by mouth every four hours as needed for general discomfort/mild pain; and - dated 3/6/23, to administer ferrous sulfate (iron supplement) 325 mg by mouth two times a day. Review of Resident 25's MAR for May 2023 showed Resident 25 was administered with ferrous sulfate medication on 5/1 and 5/2/23 at 0900 and 1700 hours, and 5/3/23 at 0900 hours. On 5/3/23 at 1412 hours, an interview was conducted with CNA 2. When asked about Resident 25's intake, CNA 2 stated Resident 25 did not get any food or liquids or snack by mouth. On 5/3/23 at 1426 hours, a concurrent interview and medical record review for Resident 25 was conducted with LVN 2. LVN 2 stated Resident 25 was NPO, and the resident's medications were given via GT. LVN 2 verified the acetaminophen and ferrous sulfate medications for Resident 25 were ordered to be given by mouth as per the physician's orders. LVN 2 verified Resident 25 was documented in the MAR to have been given ferrous sulfate by mouth on 5/2 to 5/3/23. LVN 2 stated the physician's orders for the acetaminophen and ferrous sulfate medications were confusing. LVN 2 stated he would notify the RN and would contact the physician to clarify the physician's orders for the acetaminophen and ferrous sulfate medications. On 5/4/23 at 0904 hours, a concurrent interview and medical record review was conducted with the ST. When asked about Resident 25's intake, the ST stated she worked with Resident 25 on oral gratification since admission and after four to five trials, Resident 25 was observed coughing. The ST stated Resident 25 was on GT and not able to take any medications by mouth at this time. The ST stated Resident 25 would be at risk for aspiration, aspiration pneumonia, choking, and coughing. On 5/4/23 at 0904 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified the acetaminophen and ferrous sulfate medications for Resident 25 were ordered to be given by mouth. RN 1 stated Resident 25 was on a GT feeding. RN 1 stated Resident 25 should not be given medications by mouth due to the risk of choking and aspiration pneumonia. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 12 final sampled resident (Resident 25) and two nonsampled residents (Residents 43 and 44). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 11 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few * The facility failed to provide the pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administering of medications to meet the needs of Residents 43 and 44. * The facility failed to ensure Resident 25 received the medications via GT and not PO. Resident 25 was on a GT feeding, but the ferrous sulfate and acetaminophen medications were ordered to be given by mouth as per the physician's orders. This had the potential for Resident 25 for aspiration (accidental breathing in of food or fluid into the lungs). These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Preparation and General Guidelines under Medication Administration-General Guidelines dated February 2015 showed in part, medications are administered in accordance with written orders of the attending physician. 1. Review of Resident 43's Order Summary Report showed a physician's order dated 3/20/23, to administer the following: - ascorbic acid 100 mg one tablet by mouth one time a day for supplement. - vitamin B12 Complex one tablet by mouth one time a day for supplement. Review of Resident 43's Order Summary Report showed a physician's order dated 3/24/23, to administer zinc sulfate 220 mg one capsule by mouth one time a day for supplement. On 5/3/23 at 0918 hours, during the medication pass observation with LVN 2 for Resident 43, LVN 2 stated he would not be administrating the zinc sulfate 220 mg because the facility's supply of zinc sulfate 220 mg medication was out of stock. On 5/2/23 at 1442 hours, an interview was conducted with LVN 2. LVN 2 confirmed vitamin C 500 mg and vitamin B12 1000 mcg were given to the resident during the medication pass instead of vitamin C 100 mg and vitamin B12 complex as ordered. LVN 2 stated not sure if vitamin 100 mg was available in the facility. LVN 2 was asked if vitamin B12 complex was available as the facility supply. LVN 2 stated yes and showed the following medications were available: - vitamin B12 1000 mcg - vitamin B complex with vitamin C Review of the facility's over-the-counter medication list showed vitamin B12 complex was not one of the medications stored as the facility's over the counter stock. 2. On 5/3/23 at 0918 hours, during the medication pass observation with LVN 2 for Resident 44, LVN 2 stated he would not be administrating Coreg (used to treat high blood pressure) 6.25 mg during the medication administration because Resident 44's Coreg 6.25 mg medication was out of stock. On 5/3/23 at 0918 hours, an interview was conducted with LVN 2. LVN 2 stated he was not aware Resident 44's Coreg 6.25 mg was out until he was about to administer. LVN 2 stated not sure if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 12 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 medication was refilled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 13 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 - Few 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, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 349) was free from an unnecessary psychotropic (any drug that affects brain activity) medications. * The facility failed to document the implementation of non-pharmacological interventions for crying and yelling episodes prior to the use of sertraline (antidepressant medication) and ziprasidone (antipsychotic medication) for Resident 349. This failure had the potential for Resident 349 to experience adverse effect or receive unnecessary medications. Findings: Review of the facility's P&P titled Care and Treatment for Psychotropic Drug Use revised August 2017 showed residents who use psychotropic drugs receive gradual dose reduction, and behavioral interventions, unless clinically contraindicated in an effort to discontinue these drugs. Medication record review for Resident 349 was initiated on 5/4/23. Resident 349 was admitted on [DATE]. Review of Resident 349's H&P examination dated 4/22/23, showed Resident 349 had no capacity to understand and make decisions. Review of Resident 349's Order Summary Report showed a physician's order dated 4/26/23, to administer the following: - sertraline HCL 100 mg one tablet by mouth one time a day for depression manifested by episodes of crying. - ziprasidone HCL 40 mg one capsule by mouth two times a day for schizoaffective disorder bipolar type manifested by continues yelling/screaming for no reason. a. Review of Resident 349's MAR for April and May 2023 showed the monitoring of depression as evidence by episodes of crying. The documents showed Resident 349 had the following crying episodes: - one episode on 4/24, 4/25, 4/26, 4/27, and 5/2/23; - two episodes on 4/28/23; - four episodes on 4/29/23; - five episodes on 4/30 and 5/1/23; - three episodes on 5/3/23; and - no episode on 5/4/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 14 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 - Few However, Resident 349's MAR for April and May 2023 failed to show documentation of implemented non-pharmacological interventions for crying prior to the use of sertraline (antidepressant) medication. b. Review of Resident 349's MAR for April and May 2023 showed the monitoring of psychotic behaviors as evidence by yelling out without apparent reason each shift. The documents showed Resident 349 had the following episodes of yelling without apparent reason: - four episodes on 4/23 and 5/1/23; - three episodes on 4/24, 5/2, and 5/3/23; - 10 episodes on 4/25/23; - two episodes on 4/26 and 4/27/23; - five episodes on 4/28/23; - 11 episodes on 4/29/23; and - seven episodes on 4/30/23. However, review of Resident 349's MAR for April and May 2023 failed to show documentation of implemented non-pharmacological interventions prior to the use of ziprasidone medication. On 5/4/23 at 1438 hours, concurrent interview and medical record review was conducted with LVN 1. LVN 1 was asked regarding Resident 349's behaviors. LVN 1 responded Resident 349's behaviors included episodes of yelling out for a family member, general yelling, and sometimes crying. LVN 1 was asked what non-pharmacological interventions were implemented. LVN 1 stated Resident 349 was offered ice cream, food items that were sweet which were Resident 349's preference; talking; one to one with staff when available, to be placed close to the nurse's station; and a company. LVN 1 was asked how often Resident 349's behavior was observed. LVN 1 stated at least once for his shift either crying or yelling out. LVN 1 verified the documentation failed to show non-pharmacological interventions performed during these episodes of crying and yelling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 15 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was less than 5%. Residents Affected - Few * The facility's medication error rate was 32.56%. Two of two licensed nurses (LVNs 1 and 2) were found to have made errors during the medication administration for two of 12 final sampled residents (Residents 20 and 41) and two nonsampled residents (Residents 43 and 44). This failure had the potential to negatively affect the residents' well- being. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated February 2015 showed the medications are administered in accordance with written orders of the attending physician. 1. On 5/2/23 at 0810 hours, a medication pass observation for Resident 20 and concurrent interview was conducted with LVN 1. LVN 1 was observed preparing and administering Resident 20's medications which included the following: - one tablet of Eliquis 2.5 mg (blood thinner) - one tablet of metoprolol tart 25 mg (medication for blood pressure) - one tablet of multivitamin with minerals (supplement) - one tablet of morphine sulfate IR 15 mg (medication for pain) - one liquid 10 ml of levetiracetam 100 mg/ml (medication for seizures) During an interview, LVN 1 verified there was a medication residual in the medication cup for Eliquis and multivitamin with minerals medications after administration. LVN 1 confirmed the medication residual left on the spoon. LVN 1 confirmed Resident 20 did not receive the complete dose for Eliquis and multivitamin with minerals. Review of Resident 20's Order Summary Report showed the following medications were also ordered to be administer at 0900 hours: - the physician's order dated 3/16/23, for ascorbic acid tablet 500 mg one tablet via GT one time a day for supplement and sodium bicarbonate tablet 650 mg one tablet via GT three times a day for indigestion - the physician's order dated 3/23/23, for vitamin D3 25 mcg one tablet via GT one time a day for supplement - the physician's order dated 4/27/23, for senna 8.6 mg one tablet via GT two times a day for bowel management However, LVN 1 did not administer these medications during the above medication pass observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 16 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 On 5/2/23 at 1354 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 confirmed ascorbic acid, sodium bicarbonate, vitamin D3, and senna were active orders and not given to the resident during the medication pass observation. LVN 1 stated not sure why the medications ordered did not show earlier during medication observation. 2. On 5/2/23 at 0938 hours, a medication pass observation for Resident 43 and concurrent interview was conducted with LVN 2. LVN 2 was observed preparing and administering Resident 43's medications which included the following: - one tablet of vitamin C 500 mg (supplement) - one softgel of docusate sodium 100 mg (stool softener) - one drop of dorzolamide HCL ophthalmic solution 2% (medication for glaucoma) into each eye - one drop of alphagan 0.1% (medication for glaucoma) into each eye - one tablet of vitamin B12 1000 mcg (supplement) - one tablet of vitamin D3 125 mg (supplement) - one capful of MiraLAX 3350 (medication for constipation) Durng an observation, Resident 43's Miralax cup had white residual left after administration. Review of Resident 43's Order Summary Report showed a physician's order dated 3/20/23, to administer the following at 0900 hours: - ascorbic acid 100 mg one tablet by mouth one time a day for supplement - vitamin B12 Complex one tablet by mouth one time a day for supplement On 5/2/23 at 1442 hours, an interview was conducted with LVN 2. LVN 2 confirmed vitamin C 500 mg and vitamin B12 1000 mcg were given to the resident instead of vitamin C 100 mg and vitamin B12 complex. 3. On 5/2/23 at 1008 hours, a medication pass observation for Resident 41 was conducted with LVN 2. LVN 2 was observed preparing and administering Resident 41's medications which included the following: - one tablet of lisinopril 20 mg (medication for high blood pressure) - one capsule of gabapentin 100 mg (medication for neuropathy) - one tablet of allopurinol 100 mg (medication for gout) - one tablet of multivitamin with minerals (supplement) - one tablet of vitamin C 500 mg (supplement) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 17 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 - one tablet of sodium bicarbonate 650 mg (antiacid) Level of Harm - Minimal harm or potential for actual harm - one drop of dorzolamide HCL + timolol maleate 22.3 mg/6.8 mg per ml (medication for glaucoma) into each eye. Residents Affected - Few Review of Resident 41's Order Summary Report showed a physician's order dated 4/18/23, to administer psyllium fiber oral capsule one tablet by mouth one time a day for bowel management at 0900 hours. On 5/223 at 1442 hours, an interview was conducted with LVN 2. LVN 2 confirmed the psyllium fiber capsule was not administered during the medications administration observation. 4. Review of Premier Pharmacy Services' P&P titled Specific Medication Administration Procedures under the Oral inhalation administration dated February 2015 showed breathe in and out normally through the holding chamber or spacer for one (three (3)) breaths. Wait one minute between puffs for multiple inhalations of the same medication. On 5/3/23 at 0918 hours, a medication pass observation for Resident 44 and concurrent interview was conducted with LVN 2. LVN 2 was observed preparing and administering Resident 44's medications which included the following: - one tablet of aspirin 81 mg EC (blood thinner) - one spray of azelastine HCL nasal spray 0.1% -137 mcg per spray (medication for allergies) - one spray of fluticasone propionate nasal spray 50 mcg (medication for allergies) - two tablets of furosemide 20 mg (diuretic) - two puffs of budesonide and formoterol fumarate dihydrate inhalation aerosol 160-4.5 mcg (medication for chronic obstructed pulmonary disease) - one capful of Miralax powder 3350 (medication for constipation) - one tablet of senna concentrate 8.6 mg (medication for constipation) During an interview, LVN 2 verified Resident 44 left the mouth opened after received the first and second puffs of budesonide and formoterol fumarate dihydrate inhalation. LVN 2 verified he did not wait one minute before administering the second puff to Resident 44. LVN 2 confirmed Resident 44 did not receive the full doses of medication. Review of Resident 44's Order Summary Report showed a physician's order dated 3/20/23, for the following medications to also be administered at 0900 hours: - ascorbic acid 500 mg one tablet by mouth one time a day for supplement. - multivitamin one tablet by mouth one time a day for supplement. - carvedilol 6.25 mg one tablet two times a day for hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 18 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 However, LVN 2 did not administer these medications during the above medication pass observation. Level of Harm - Minimal harm or potential for actual harm On 5/3/23 at 1006 hours, a review of Resident 44's MAR and concurrent interview with LVN 2 was conducted. Resident 44's MAR indicated vitamin C 500 mg tablet and multivitamin tablet were marked as given. Vitamin C and multivitamin were not observed administered to the resident during Resident 44's medication observation. During the medication administration observation, LVN 2 confirmed there were four pills, two nasal, one powder, and one inhalation were prepared prior to administration to Resident 44. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 19 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observatioon, interview, medical record review, and facility P&P, the facility failed to ensure two nonsampled residents (Residents 15 and 44) were free from the significant medication errors. Residents Affected - Few * The facility failed to document Resident 15's controlled medication (medications that have some potential for abuse or dependence) administration and follow the physician's orders. * The facility failed to administer Resident 44's carvedilol (medication used to control high blood pressure) during the medication observation. These failures placed Residents 15 and 44 at risk for medical complications. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Controlled Medications dated February 2015 showed when medication is administered, the license nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1. Date and time of administration. 2. Amount administered. 3. Signature of the nurse administering the dose, completed after the medication is actually administered. Review of the facility's P&P titled Medication Administration-General Guidelines dated February 2015 showed the medications are administered in accordance with written orders of the attending physician. 1. Medical record review for Resident 15 was initiated on 5/02/23. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's Order Summary Report showed a physician's order dated 9/13/22, to administer hydrocodone-Acetaminophen (narcotic pain medication, generic name for Norco) tablet 10-325 mg one tablet by mouth every eight hours as needed for moderate to severe pain. Review of Resident 15's Record of Controlled Substance log showed Norco 10-325 mg tablet was removed from the resident's bubble pack (a card where medications are placed in individual clear sealed bubbles) on 5/3/23 at 0500 and 0855 hours, approximately four hours apart instead of eight hours as ordered. Review of Resident 15's MAR for May 2023 showed no documented evidence of Norco 10/325 mg administration on 5/3/23 at 0500 hours. The MAR showed a dose of Norco was administered at 0900 hours on 5/3/23. Due to lack of documentation for medication administration at 0500 hours, the Norco administered at 0900 hours was given four hours sooner than the prescribed dose, every eight hours as needed. On 5/3/23 at 1456 hours, an interview was conducted with Resident 15. Resident 15 was asked if she took medication for pain. Resident 15 responded yes, Norco for pain and Baclofen (muscle relaxant medication) for nerve pain. Resident 15 was asked if she recalled having pain between 0500 to 0530 hours this morning. Resident 15 did not recall. Resident 15 stated always having pain but only requested for pain medication if having a lot of pain. Resident 15 recalled taking the pain medication later in the morning before getting ready for the council meeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 20 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/3/23 at 1315 hours, an interview and concurrent medical record review for Resident 15 was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 confirmed on 5/3/23 at 0500 hours, Norco 10/325 mg was not documented as administered on the MAR. LVN 1 confirmed administering Norco 10/325 mg on 5/3/23 at 0900 hours. On 5/4/23 at 0746 hours, an interview was conducted with LVN 3. LVN 3 was asked what happened in the morning of 5/3/23. LVN 3 stated when responded to Resident 15's call light, Resident 15 reported having pain and requested for pain medication. LVN 3 stated he administered the pain medication and forgot to document on the MAR (on 5/3/23 at 0500 hours). LVN 3 was asked what could occur if the medication administered was not documented. LVN 3 stated a risk for the resident, the residents could have side effects such as lethargy, nausea, and vomiting. LVN 3 was asked about Resident 15's prescribed order for Norco. LVN 3 stated Norco one tablet was ordered every eight hours as needed. LVN 3 was asked if there was significance medication error. LVN 3 confirmed a medication error occurred and the Norco medication was given earlier than prescribed. LVN 3 confirmed he was aware of Resident 15 receiving Norco on 5/3/23 at 0900 hours. LVN 3 was asked what could happen if the resident received the medication sooner than prescribed. LVN 3 responded the resident could have lethargy, nausea, vomiting, and tremors. LVN 3 was asked what the process for documenting and administering the resident's controlled medication. LVN 3 stated to sign the MAR, administer the medication, then document on the controlled log. LVN 3 was asked if that practice was in accordance with the facility's policy. LVN 3 responded yes. LVN 3 was asked what process LVN 3 followed on 5/3/23. LVN 3 stated removing the medication, then signed on the controlled log but not documented on the MAR. LVN 3 confirmed not following the facility's policy. On 5/5/23 at 1105 hours, an interview was conducted with the DON. The DON was asked regarding the process when administering and documenting the controlled medication. The DON stated to sign the controlled log, administer the medication, then sign the MAR after medication administration. The DON confirmed LVN 3's process was incorrect. 2. Medical record review for Resident 44 was initiated on 5/03/23. Resident 44 was admitted to the facility on [DATE]. Review of Resident 44's H&P examination dated 3/22/23, showed Resident 44 had the capacity to understand and make decisions. Review of Resident 44's Order Summary Report dated 5/1/23, showed a physician's order dated 3/30/23, to administer carvedilol 6.25 mg one tablet by mouth two times a day for hypertension, hold if SBP <110 mmHg or pulse < 65 beats per minute. On 5/3/23 at 0918 hours, during the medication pass observation with LVN 2 for Resident 44, LVN 2 verified the carvedilol medication was not available in the facility and not sure if it was refilled. LVN 2 verified the ordered medication was not administered to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 21 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 7. On 5/4/23 at 1230 hours, a medication cart parked in the hallway by the Rehabilitative Department was observed with a bottle of acetaminophen medication on top of the cart unattended. The resident and visitors from Room A were observed passing by the cart in the hallway. On 5/4/23 at 1238 hours, an interview was conducted with LVN 5. LVN 5 verified and acknowledged the above findings. LVN 1 further stated the medications should not be left unattended. On 5/5/23 at 0830 hours, an interview was conducted with the DON. The DON was informed of the above findings. The DON acknowledged the findings and further stated the medications should be secured and not left unattended. Based on observation, interview, facility P&P review, and facility pharmacy P&P, the facility failed to ensure the medications and supplies were properly stored. * LVN 1 left MiraLAX (medication for constipation) unattended on the medication cart. * Multiple expired medications and supplies were observed in the central supply room. * Oral and suppository medications were stored next to each other on the same shelf in the central supply room. * Expired wound care supplies were observed in the treatment cart. * Expired IV supplies were observed in the IV cart. * Medication labeled for a resident was opened, used, and stored in the central supply room. * The facility failed to store a bottle of acetaminophen (pain medication) securely and inaccessible by the staff, residents, and visitors. This had the potential for unauthorized access to the medication. These failures had the potential to result in unsafe medication administration and wound care treatment. Findings: Review of the Pharmacy Services' P&P titled Medication Storage in the Facility under storage of medications dated February 2015, showed the following: - Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. - During administration of medications, the medication cart is kept closed and locked when out of sight of medication nurse or aide. No medications are kept on top of the cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 22 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0761 Level of Harm - Minimal harm or potential for actual harm - Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. - Medications labeled for individualized residents are store separately from floor stock medications when not in the medication cart. Residents Affected - Some - Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Review of the Pharmacy Services' P&P titled Medication Ordering and receiving under medication labels dated February 2015, showed floor stock medications are labeled as floor stock or house supply and kept in the original manufacturer's container. The manufacturers or pharmacy's label should include the following: medication name, medication strength, quantity, accessory instructions, lot number and expiration date. 1. On 5/2/23 at 0901 hours, an observation and concurrent interview conducted with LVN 1. The MiraLAX medication was observed being left unattended on the medication cart. LVN 1 was asked about the MiraLAX medication and acknowledged the medication should not be left unattended. 2. On 5/3/23 at 0806 hours, an inspection of central supply room and concurrent interview was conducted with RN 1. The following was identified: - Acetic acid 0.25% (for urological irrigation) 500 ml had expired on 3/22. - Toothette oral care suction swabs (x 40) had expired on 2/25/20. - a trach T adapter with drainage bag (x 2) had expired on 5/20/22. - hypodermic needle 25 G 1-1/2 (x 3) had expired on 4/18. - nitro syringe 5 ml (x 7) had expired on 8/19. - freedom cath 28 mm (x 6) had expired on 8/6/22. - freedom cath 28 mm (x 2) had expired on 10/12/22. - freedom cath 35 mm (x 7) had expired on 9/22/22. - freedom cath 23 mm (x 7) had expired on 8/25/22. - iodosorb cadexomer iodine gel (x 7) had expired on 7/22. - Foley catheter pure gold ptfe coated size French 24 had expired on 11/28/21. - Foley catheter pure gold ptfe coated size French 24 had expired on 1/28/22. - Foley catheter 26 French siliconized (x 7) had expired on 1/17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 23 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0761 - Zinc oxide ointment skin protectant x 1 with no expiration date, other zinc oxide ointment x 4 were dated with an expiration date. Level of Harm - Minimal harm or potential for actual harm - dermoplast first aid spray (x 1) had expired on 06/22. Residents Affected - Some - dermafilm HD hydrocolloid wound dressing 4x4 had expired on 3/12/23. - a half-full bottle of Dakin's solution sodium hypochlorite 0.50% had no label of expiration date. RN 1 confirmed the expired medications and supplies. RN 1 confirmed Dakin's solution sodium hypochlorite 0.50% was half emptied with no expiration date. 3. On 5/3/23 at 0806 hours, an inspection of central supply room and concurrent interview was conducted with RN 1. The following was identified: - Dulcolax suppository (medication for constipation) 10 mg (box of 13) was observed on the same shelf as Tylenol (medication for pain relief) 325 mg 20 liquid gels, milk of magnesium (medication for constipation) bottles, Mucinex 600 mg ER bilayer tablets (x 20 container x 2), Mucus DM ER 1200 mg/60 mg packet (14 tabs), and Unna Boot with Zinc (x 3 boxes). RN 1 confirmed findings and acknowledged the oral medications and external used medications were on the same shelf. 4. On 5/3/23 at 1353 hours, an inspection of the treatment cart and concurrent interview was conducted with LVN 4. The following was identified: - Puracol plus microscaffold collagen wound dressing (x 1) had expired on 10/21. - lubricating jelly (x 6) had expired on 11/6/22. - lubricating jelly packet (x 1) had expired on 4/28/23. - lubricating jelly packet (x 1) had expired on 01/20. - Partial used package of alginate wound dressing with antibacterial silver (sterile product). LVN 4 confirmed those were the expired supplies. LVN 4 was asked what the practice of dressing storage. LVN 4 stated the practice was to dispose of the partial used dressing. 5. On 5/3/23 at 1110 hours, an inspection of the IV cart and concurrent interview was conducted with RN 1. The following was identified. - an extension set 15-inch 1.2-micron filter secure lock (x 1) had expired on 4/1/22. - a secondary set secure lock 34 inch with IV set hanger (x 1) had expired on 11/1/22. RN 1 confirmed the expired supplies. 6. On 5/3/23 at 0806 hours, an inspection of central supply room and concurrent interview was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 24 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0761 Level of Harm - Minimal harm or potential for actual harm conducted with RN 1. The miconazole nitrate (antifungal medication) 2 % powder 2.5 oz labeled for a resident was opened and used. RN 1 confirmed the medication should be stored in the medication cart and not in central supply room. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 25 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. Residents Affected - Few * The facility failed to ensure the correct texture of fish and noodles were served. Chopped fish and whole noodles were served instead of ground fish and softly chopped noodles for the residents on the dysphagia mechanical soft diet (diet consists of foods that are moist soft-textured and easily formed into a bolus, meant for people with chewing and swallowing difficulties) as per the facility's menu. This failure had the potential for the residents not receiving the correct food texture and could potentially result to choking. Findings: Review of the CMS-672 form titled Resident Census and Conditions of Residents completed by the facility dated 5/2/23, showed 42 of 54 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menu Planning undated, showed the menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, physician's orders, and to the extent medically possible, in accordance with the most recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility RD prior to the beginning of each quarterly menu cycle. Review of the facility's document titled Diet Order Tally Report - Selected Textures dated 5/5/23, showed one resident was on a dysphagia mechanical soft diet, with no restrictions to fish and noodles. Review of the facility's document titled Spring Cycle Menus for 5/4/23, showed to serve ground teriyaki fish and soft-chop imperial noodles for a dysphagia mechanical soft diet. On 5/4/23 at 1205 hours, during the trayline observation with the DSS present, the [NAME] was observed serving chopped teriyaki fish and whole imperial noodles for a dysphagia mechanical soft diet instead of ground teriyaki fish and soft-chop imperial noodles as per the facility's menu. The [NAME] and DSS verified the findings. The DSS verified the diet spreadsheet showed to serve ground teriyaki fish and softly chopped imperial noodles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 26 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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, facility documents review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure the food items in the refrigerator and resident refrigerator were properly labeled. * The facility failed to ensure the resident refrigerator and the bin containing the scoops were clean. * The facility failed to ensure the kitchen utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 - Resident Census and Conditions of Residents completed by the facility dated 5/2/23, showed 43 of 46 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Labeling and Dating of Foods (undated) showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated on established procedures for either food safety or product rotation. For foods that are commercially processed, ready to eat and intended to be stored cold greater than 24 hours will be marked with a use by date. The use by date will incorporate the open date for TCS foods (time/temperature control for safety foods, require time and temperature controls to limit the growth of bacteria) as defined by the Federal Food Code. The use by date signifies the date in which food must be consumed or discarded. The dating once opened, but require refrigeration are included on the Dry Good Storage Guidelines or Refrigerated Storage Guide. Review of the facility's document titled Dry Goods Storage Guidelines 2018 showed the fruit juices that were opened and refrigerated are good for five days. Review of the facility's document titled Refrigerated Storage Guidelines 2019 showed the maximum refrigeration time for cream cheese and sour cream is to follow the expiration date or seven days after opening, whichever comes first. On 5/2/23 at 0754 hours, during the initial tour of the kitchen, the following was observed: - a tray containing several cups of juices with a prepared date of 4/2/23; - a container of pasteurized cream cheese with a delivery date of 1/4/23, was observed open with no opened date; and - a container of sour cream was observed with no delivery date and opened date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 27 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DSS verified the above findings. The DSS discarded the containers of cream cheese and sour cream. The DSS stated the dietary staff had mistakenly wrote 4/2/23, instead of 5/2/23, on the label for the fruit juices. 2. Review of the facility's P&P titled Foods Brought by Family or Visitor revised date 7/21/21, showed the residents' food shall be stored in the facility in the following locations: resident refrigerator or in the kitchen. The Residents' food stored in the facility kitchen will be easily distinguishable from facility food. All foods shall be labeled with the resident's name, location, and date. On 5/2/23 at 0835 hours, an observation of the residents' refrigerator in the dining room was conducted with the DSS. An opened bottle of soda was observed inside the resident refrigerator with no label with the resident name, location, and date on the bottle. The DSS verified the findings. 3. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact and utensils shall be clean to sight and touch. Review of the facility's P&P titled Sanitation 2023 showed the FNS (Food and Nutrition Services) Director is responsible for instructing FNS personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, crack, and chipped areas. a. On 5/2/23 at 0835 hours, the residents' refrigerator was observed with a brown liquid at the bottom of the refrigerator and dirty. The DSS verified the findings. b. On 5/5/23 at 1108 hours, a bin containing the scoops was observed with brown particles. A scoop inside the bin was also observed with brown particle. The DSS verified the findings. 4. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. On 5/4/23 at 1147 hours, three white rubber spatulas were observed to be chipped. The DSS verified the findings. 5. According to the USDA Food Code 2022, 4-501.12, Cutting Surfaces, surfaces such as cutting blocks that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 5/5/23 at 1108 hours, several cutting boards were observed to be heavily marred with knife marks. The DSS verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 28 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 Based on observation, interview, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. Residents Affected - Some * The facility failed to ensure Resident 500's family member wore the required personal protective equipment when entering a contact precaution room (Room B). * The facility failed to ensure the infection control practices were maintained in the facility's storage room for cleaning supplies when the personal belongings of staff were stored with the cleaning supplies as per the facility's policy. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when a dusty fan and air conditioning unit with dusted air vent were observed in the clean linen area. * The facility failed to ensure the staff wore the required personal protective equipment in an isolation precaution room (Room A) and changed personal protective equipment when assisting between residents in Room A. * The facility failed to ensure the nursing staff performed hand hygiene between glove changes during medication administration. * The facility failed to ensure the nursing staff followed proper infection control practices during the IV medication administration. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents and staff. Findings: 1. Review of the facility's document titled Respiratory, Droplet, and Contact Precaution undated showed to wash hands, wear gloves, gown, N95 mask, and face shield. Further review of the facility's record showed 9B - cough and to Stop - please report to the nurse before entering. On 5/2/23 at 0815 hours, during the initial tour of the facility, a sign showing Respiratory, Droplet, and Contact Precaution with instructions to perform hand washing, wear gloves, gown, N95 mask, and face shield was posted at the entry of Room B. On 5/2/23 at 0818 hours, an interview was conducted with LVN 2. LVN 2 stated Bed B resident was on contact isolation for cough in Room B. On 5/2/23 at 1111 hours, an interview was conducted with CNA 6. CNA 6 stated Bed B in Room B was on contact precaution. CNA 6 further stated he would wear the required personal protective equipment as showed on the sign outside Room B when entering the room. On 5/2/23 at 1216 hours, a concurrent observation and interview was conducted with Resident 500's family member. Resident 500's family member was observed inside Room B sitting on the chair beside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 29 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 Residents Affected - Some Bed B without a gown, gloves, mask and face shield. Facility staff was observed passing in the hallway of Room B. On 5/2/23 at 1221 hours, an interview was conducted with Resident 500's family member. Resident 500's family member stated she was not aware of the sign outside and was not informed of what to do before entering Room B. On 5/2/23 at 1228 hours, an interview was conducted with CNA 6. CNA 6 verified and acknowledged the above findings. CNA 6 stated Resident 500's family member should be wearing the personal protective equipment when went inside Room B to prevent the spread of infections. On 5/2/23 at 1232 hours, a concurrent observation and interview was conducted with LVN 2 and Resident 500's family member. LVN 2 was observed instructing Resident 500's family member to wear the required personal protective equipment and Resident 500's family member complied. LVN 2 verified and acknowledged the above findings. On 5/4/23 at 1612 hours, and interview was conducted with the DSD/IP. The DSD/IP was informed and acknowledged the above findings. The DSD/IP stated personal protective equipment should be worn in isolations rooms. 2. Review of the facility's P&P titled Infection Control Policy/Procedure, Housekeeping Department under Personnel Guidelines section revised on 3/12/20, showed employees are provided with locker for personal items/belongings during their shift. On 5/3/23 at 0847 hours, an inspection of the storage room for the cleaning supplies was conducted with the Housekeeping. Several personal belongings were observed in the storage room of cleaning supplies as follows: - a jacket on top of the wet floor sign, - a backpack hanging on the wet floor sign, - a sealed plastic bag of oranges, two gray cups, multiple bottled water, one sealed jar of disposable utensils, one silver tumbler, and one black basket on the first shelf, - a plastic bag of disposable cups and bowls, and two brown plates on the second shelf, - a plastic bag of disposable plates on the third shelf and an opened box of instant noodles on the far end of the third shelf, and - several jackets hanging on the wall beside the rack of clean rags. The Housekeeping verified and acknowledged the above findings. The Housekeeping staff stated they did not have a locker for their personal belongings. On 5/3/23 at 0901 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified and acknowledged the above findings. 3. Review of the facility's P&P titled Infection Control Policy/Procedure, Laundry Department (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 30 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 revised on 2/2022 showed it is the facility's policy to follow careful precautionary procedures by the laundry personnel to prevent the spread of infectious disease to other staff members, residents, and visitors. Further review of the facility's policy showed an air flow from the fans and exhaust systems in the laundry areas will be from clean to soiled in direction to prevent airborne contamination and all fans and exhaust systems will be kept clean. Residents Affected - Some Review of the facility's document titled Work History Report undated showed the exhaust fans were inspected for proper operation and clean if necessary. Further review of the facility's document showed the Maintenance Director marked it was done on 4/10/23. On 5/3/23 at 0914 hours, a laundry area inspection was conducted with the laundry staff. One small white portable fan was observed clipped to the shelf of the cabinet with folded clean linens accumulated with dust on the grill metal cover of the fan in the clean laundry area. One air conditioning unit accumulated with dust on the air flow vents that was on the wall above the clean linen folding area. On 5/3/23 at 0923 hours, a concurrent observation and interview was conducted with the Maintenance Director. The Maintenance Director verified and acknowledged the above findings and stated the fans and air conditioning unit were used as needed and cleaned monthly. On 5/3/23 at 0927 hours, an interview was conducted with the DSD/IP. The DSD/IP was informed of the above findings. The DSD/IP stated the fan and air conditioning unit in the clean laundry area should be cleaned. The DSD/IP stated personal belongings should be stored in the designated lockers. 4. According to CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings dated 5/2022, under the section IV. Standard Precautions IV. B Personal Protective Equipment Gowns IV.B.3.c showed to not reuse gowns, even for repeated contacts with the same patient. Review of the facility's P&P titled Infection Prevention - Control of Transmission of Infection undated under Standard Precautions including Contact Precautions - Protective Barriers section showed to wear disposable gowns when entering room or cubicle and it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces (such as siderails or bed linens of an infected resident) is anticipated. Remove gowns when the procedure is complete and prior to leaving the resident's room. On 5/4/23 at 1248 hours, CNAs 2 and 3 were observed inside of Room A. An isolation precaution sign was observed outside of Room A. CNA 3 was observed assisting the residents in Beds A and B using the same isolation gown between the residents. CNA 2 was observed wearing gloves; however, CNA 2 was not wearing an isolation gown. On 5/4/23 at 1250 hours, an interview was conducted with CNA 2. When asked about the residents in Room A were on isolation, CNA 2 answered yes. CNA 2 verified and acknowledge the above findings. CNA 2 stated he was helping CNA 3 pulling up the residents in Beds A and B. CNA 2 further stated he should wear a gown because he touched the linens of the residents on isolation. On 5/4/23 at 1257 hours, an interview was conducted with CNA 3. CNA 3 stated in-between residents care should be changing gown and gloves. CNA 3 further stated gowns were not changed when pulling up the residents in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 31 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 Residents Affected - Some On 5/4/23 at 1144 hours, an interview was conducted with LVN 5. LVN 5 acknowledge the above findings and stated gowns should be changed when assisting between the residents to prevent the spread of infection. 5. Review of facility's P&P titled Preparation and General Guidelines medication administration general guidelines under administration dated February 2015 showed hands are washed before and after administration of topical, ophthalmic, otic, parenteral, enteral, rectal and vaginal medications. On 5/2/23 at 1008 hours, a medication pass observation for Resident 41 was conducted with LVN 2. LVN 2 was observed preparing and administering Resident 41's medication which included a total of five medications to be administered orally and dorzolamide HCL + timolol maleate 22.3 mg/6.8 mg per ml (medication for glaucoma) to be administered one drop in each eye. The following were observed: - LVN 2 performed hand washing prior to donning gloves to administer the medications to Resident 41. LVN 2 proceeded with instillation of dorzolamide HCL + timolol maleate one drop to the right eye. LVN 2 was observed not performing hand hygiene between glove change. On 5/2/23 at 1008 hours, an interview was conducted with LVN 2 . LVN 2 was asked if hand hygiene was performed in between administration of eye drop and glove change. LVN 2 acknowledged hand hygiene was not performed between eye drop administration and glove change. 6. On 5/3/23 at 0918 hours, a medication pass observation for Resident 44 was conducted with LVN 2. LVN 2 was observed administering the medications, including azelastine HCL nasal spray 0.1% -137 mcg per spray (medication for allergies) and fluticasone propionate nasal spray 50 mcg (medication for allergies). LVN 2 performed hand washing prior to donning gloves to administer the medications for Resident 44. LVN 2 proceeded with administration of azelastine HCL nasal spray to the left nostril, removed gloves, donned gloves, and administered nasal spray to the right nostril. LVN 2 proceeded with administration of fluticasone propionate nasal spray to the left nostril, removed gloves, donned new gloves, and administered the medication to the right nostril. LVN 2 was not observed performing hand hygiene in between administration of nasal medications and between glove changing. On 5/3/23 at 0930 hours, an interview was conducted with LVN 2. LVN 2 was asked if hand hygiene was performed in between administration of nasal spray medications and glove changes. LVN 2 acknowledged hand hygiene was not performed between nasal spray administration and glove changes. 7. Review of the facility's P&P titled Preparation and General Guidelines under reconstitution of medication for parenteral administration dated February 2015 showed to provide for safe and accurate reconstitution of parental medications prior to administration, manufacturer information is reviewed, and aseptic technique is observed. Under the procedures section showed the following: - Wash hands thoroughly. - Break and remove seal from vial of diluent and wipe rubber stopper with alcohol swab. - Swab rubber stopper on medication vial with alcohol wipe. Review of the facility's P&P titled Policy II-A Continuous infusion of Medications and Solutions under procedures dated January 2021 showed to gather equipment, prepare appropriate work area, and wash hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 32 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 Residents Affected - Some On 5/2/23 at 1400 hours, an IV medication administration observation for Resident 648 was conducted with RN 1. RN 1 prepared one IV medication, piperacillin and tazobactam (antibiotic) for injection 2.25 gram vial. On 5/2/23 at 1400 hours, RN 1 performed hand hygiene with sanitizer. RN 1 gathered one IV tubing, one 0.9% sodium chloride 100 ml, and one piperacillin and tazobactam (antibiotic to treat infection) injection vial; and placed the supply and medication on top of IV cart. RN 1 was observed not disinfecting preparing area, IV cart. RN 1 removed the seal of the piperacillin and tazobactam injection vial and proceeded to mix with 0.9% sodium chloride. RN 1 was observed not swabbing rubber stopper of piperacillin and tazobactam vials with alcohol wipe prior to mixing. On 5/2/23 at 1430 hours, an interview was conducted with RN 1. RN 1 was asked if hand washing was performed prior to prepping the IV medication. RN 1 confirmed hand washing was not performed, and hand hygiene was performed with sanitizer. RN 1 was asked if the preparation area, the IV chart surface was disinfected prior to preparation. RN 1 confirmed the IV cart surface was not disinfected. RN 1 was asked if the piperacillin and tazobactam vial's rubber stopper was swabbed with alcohol. RN 1 confirmed the rubber stopper was not swabbed with alcohol and the practice was to cleanse when contaminated. RN 1 acknowledged not following the proper practice. 8. On 5/2/23 at 0810 hours, a medication observation was conducted for Resident 20 with LVN 1. LVN 1 prepared Eliquis (blood thinner) one tablet and placed in the medication cup. LVN 1 was observed placing the medication cup with Eliquis in LVN 1's pocket. On 5/2/23 at 0840 hours, an interview was conducted with LVN 1. LVN 1 was asked if the medication cup with the Eliquis medication should have placed in LVN 1's pocket. LVN 1 confirmed that practice should not have been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 33 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0908 Keep all essential equipment working safely. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the freezer compartment inside the resident refrigerator was free of ice buildup. This had the potential for the refrigerator not being maintained in safe operating condition. Residents Affected - Some Findings: On 5/2/23 at 0835 hours, an inspection of the residents' refrigerator was conducted with the DSS. The surrounding of the freezer compartment of the residents' refrigerator was observed with a build-up of ice. The DSS verified the above findings. The DSS stated the dietary staff cleaned the resident refrigerator every night and tossed the expired food items after three days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 34 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to inspect the bed frames, mattress, and side rails to identify areas of possible entrapment for three of 12 final sampled residents (Residents 33, 398, and 499). This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bedrail Assessment revised 8/2017 showed it is the policy of the facility to assess the use of bedrails and the facility must ensure correct installation, use, and maintenance of bed rails. When installing and using bed rails, the facility should: a. Ensure that the bed's dimensions are appropriate for the resident. b. Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed. c. Install bed rails using the manufacturer's instructions to ensure a proper fit. d. Inspect and regularly check the mattress and bed rails for areas of possible entrapment. e. Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body. Gaps can be created by movement or compression of the mattress which may be caused by resident weight, resident movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed. f. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 35 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0909 - Zone 5: between split bed rails; Level of Harm - Minimal harm or potential for actual harm - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Residents Affected - Few 1. On 5/2/23 at 0849 hours, 5/3/23 at 0810 and 1032 hours, and 5/4/23 at 1009 hours, Resident 398 was observed in bed with the bilateral grab bars elevated. Medical record review for Resident 398 was initiated on 5/2/23. Resident 398 was admitted to the facility on [DATE]. Review of Resident 398's MDS 2/20/23, showed Resident 398 had a severe cognitive impairment. Resident 398 required one-person assistance for bed mobility and two-person assistance for transfer. Review of Resident 398's Order Summary Report showed a physician's order dated 4/20/23, for bilateral grab bars when in bed as enabler for bed mobility, turning, repositioning, and transfer. Review of Resident 398's Bed Rail Evaluation dated 4/20/23, showed Resident 398 needed the bed rails for positioning/support and/or rising from supping to sitting/standing position as a mobility enabler. On 5/3/23 at 1055 hours, an interview was conducted with CNA 1. When asked about Resident 398's grab bars, CNA 1 stated Resident 398 could move her hands and arms and hold on to the grab bars to reposition herself. On 5/3/23 at 1358 hours, an interview and concurrent facility document review for Resident 398 was conducted with the Maintenance Director. The Maintenance Director verified the above findings. When asked about the bed inspection process, the Maintenance Director stated the maintenance department was responsible to inspect the bed every month, and annually. The Maintenance Director stated he checked the mattress, bed frame, side rails, power control, the head and foot part of the mattress, up and down function of the bed, and the head and leg function of the bed. The Maintenance Director stated he visually inspected the beds monthly and another visual inspection and measurement of the length and width of the bed annually. The Maintenance Director stated he installed Resident 398's grab bars. When asked if Resident 398's bed was inspected in the seven areas/zones of the bed where there was a potential for entrapment, the Maintenance Director answered no and stated he did not check the different zones of the bed for possible areas of entrapment because Resident 398 had grab bars and not side rails. The Maintenance Director stated the grab bars were not side rails. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment were present based on the change of the bed, mattress, or user, the Maintenance Director answered he would only measure the head of the bed, and not the sides of the bed, because the measurement on the side of the bed would always be the same. The Maintenance Director stated he only checked for possible areas of entrapment on the different zones annually because the equipment they used was expensive. On 5/3/23 at 1630 hours, a follow-up interview and concurrent facility document record review for Resident 398 was conducted with the Maintenance Director. The Maintenance Director stated he did the annual bed inspection this month. The Maintenance Director stated he only checked the length and the width of the bed. When asked to show documentation of his bed inspection, the Maintenance Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 36 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0909 showed and verified the following documents: Level of Harm - Minimal harm or potential for actual harm - Review of the facility document titled Bed Inspection showed Resident 398's bed was inspected on 1/2, 2/6, 3/6, 4/17, and 5/3/23. The document showed on 5/3/23, the following was inspected: power cord, controller, wires, wheels, brakes, bed frame, full and smooth operation of the bed, headboard and foot board. However, the mattress was not check for damage, the gap between the bed and mattress were not check, the left and right mobility bars were not checked, and the bed frame, mattress and rails were not checked to be adequately fit and if compatible. Residents Affected - Few - Review of the Bed Inspection Form (undated) showed the width and length of Resident 398's bed and mattress were measured. However, the seven zones were left blank; and - Review of the facility document (untitled and undated) showing the different zones inspection only showed Resident 398's bed number. The different zones inspection were left blank and did not show whether the bed passed or failed. 2. On 5/2/23 at 0823 hours, a concurrent observation and interview was conducted with Resident 33. Resident 33 was observed in bed with the bilateral grab bars elevated. Resident 33 stated she used the bilateral grab bars to assist her with repositioning and transferring out of bed. On 5/3/23 at 1050 hours, Resident 33 was observed in bed with bilateral grab bars elevated. Medical record review for Resident 33 was initiated on 5/2/23. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's MDS dated [DATE], showed Resident 33 was cognitively intact. Resident 33 required one-person assistance for bed mobility and two-person assistance for transfer. Review of Resident 33's Order Summary Report showed a physician's order dated 3/13/23, for bilateral grab bars when in bed as enabler for bed mobility, turning, repositioning, and transfer. Review of Resident 33's Bed Rail Evaluation dated 3/13/23, showed Resident 33 needed the bed rails for positioning/support and/or rising from supine to sitting/standing position as a mobility enabler. On 5/3/23 at 1053 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 33 used the grab bars to help her reposition in bed. 3. On 5/2/23 at 0938 hours, a concurrent observation and interview was conducted with Resident 499. Resident 499 was observed in bed with bilateral grab bars elevated. Resident 499 stated she used the bilateral grab bars to assist her with repositioning and transferring out of bed. Medical record review for Resident 499 was initiated on 5/2/23. Resident 499 was admitted to the facility on [DATE]. Review of Resident 499's H&P examination dated 4/27/23, showed Resident 499 had the capacity to understand and make decisions. Review of Resident 499's Order Summary Report showed a physician's order dated 4/30/23, for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 37 of 38 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 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 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 0909 bilateral grab bars when in bed as enabler for bed mobility, turning, repositioning, and transfer. Level of Harm - Minimal harm or potential for actual harm Review of Resident 499's Bed Rail Evaluation dated 4/30/23, showed Resident 499 needed the bed rails for positioning/support and/or rising from supine to sitting/standing position as a mobility enabler. Residents Affected - Few On 5/3/23 at 1053 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 499 used the grab bars to help her reposition in bed. On 5/3/23 at 1358 hours, an interview and concurrent facility document review for Resident 33 and 499 was conducted with the Maintenance Director. The Maintenance Director verified the above findings. When asked about the bed inspection process, the Maintenance Director stated the maintenance department was responsible to inspect the bed every month and annually. The Maintenance Director stated he checked the mattress, bed frame, side rails, power control, the head and foot part of the mattress, up and down function of the bed, and the head and leg function of the bed. The Maintenance Director stated he visually inspected the beds monthly and then another visual inspection and measurement of the length and width of the bed annually. The Maintenance Director stated he installed Residents 33 and 499's grab bars. When asked if Residents 33 and 499's beds were inspected for the seven areas/zones of the bed where there was a potential for entrapment, the Maintenance Director answered no and stated he did not check the different zones of the bed for possible areas of entrapment because Residents 33 and 499 had grab bars and not side rails. The Maintenance Director stated the grab bars were not considered as side rails. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment are present based on the change of the bed, or mattress, or user, the Maintenance Director answered he would only measure the head of the bed, and not the sides of the bed, because the measurement on the side of the bed would always be the same. The Maintenance Director stated he only checked for possible areas of entrapment on the different zones annually because the equipment they used was expensive. On 5/3/23 at 1411 hours, a concurrent interview and facility document record review for Residents 33 and 499 was conducted with the Maintenance Director. The Maintenance Director stated he did the annual bed inspection this month. The Maintenance Director stated he only checked the length and width of the bed. When asked to show the documentation of his bed inspection, the Maintenance Director showed and verified the following documents: - Review of the facility document titled Bed Inspection showed Resident 33 and 499's bed was inspected on 1/2, 2/6, 3/6, 4/17, and 5/3/23. The documents showed on 5/3/23, the following was inspected: power cord, controller, wires, wheels, brakes, bed frame, full and smooth operation of the bed, headboard, and foot board. However, the mattress were not check for damage, the gap between the bed and mattress were not check, the left and right mobility bars were not checked, and the bed frame, mattress and rails were not checked to be adequately fit and if compatible. - Review of the Bed Inspection Form (undated) showed the width and length of Residents 33 and 499's beds and mattresses were measured. However, the seven zones were left blank. - Review of the facility document (untitled and undated) showing the different zones inspection only showed Residents 33 and 499's bed numbers. The different zones inspection were left blank and did not show whether the bed inspection was passed or failed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 38 of 38