Health inspection·November 23, 2022

F 0692 Provide enough food/fluids to maintain a resident's health. 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 one of 19 final sampled residents (Resident 14) was administered the prescribed enteral formula (liquid nourishment administered through a GT) as ordered by the physician. This failure posed the risk for Resident 14 to have unplanned weight loss. Residents Affected - Few Findings: During the tour of the facility on 11/17/22 at 0758 hours, Resident 14 was observed lying in bed with a continuous feeding pump infusing at 70 ml per hour from a 1500 ml bottle of Jevity (fiber-fortified tube-feeding formula) 1.5 Cal Medical record review for Resident 14 was initiated on 11/17/22. Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the physician's order dated 11/14/22, showed to administer Jevity 1.5 Cal at 80 ml per hour via GT for 20 hours to provide 1600 ml/2400 calories. On 11/17/22 at 0813 hours, an observation and concurrent interview was conducted with the ADON and DON. The ADON and DON verified the rate of the enteral formula administered to Resident 14 was incorrect. The ADON and DON stated Resident 14 should be administered Jevity 1.5 Cal at 80 ml per hour as per the physician's order. The DON then adjusted the rate of the feeding pump to 80 ml per hour. On 11/17/22 at 1523 hours, a follow-up interview was conducted with the DON. When asked what was the possible harm of not receiving the GT feeding as prescribed by the physician, the DON replied it could result in Resident 14's dehydration and weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 2 of 8 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the respiratory care to meet the needs for one of 19 final sampled residents (Resident 64). The facility failed to ensure the mechanical ventilator low pressure alarm for Resident 64 was set within the safe parameters as per the facility's P&P. This posed the risk for delayed care and interventions if the resident's ventilator alarm was not trigerred when it should have, to alert the staff the resident was in distress or disconnected from their ventilator. Residents Affected - Few Findings: Review of the facility's P&P titled Mechanical Ventilation (undated) showed to set the ventilator low pressure alarm 5 to 10 cmH2O below the PIP. According to the Clinical Application of Mechanical Ventilation 2014, Fourth Edition, the low-pressure alarm is triggered if the PIP is less than the alarm setting. Conditions that may trigger the low-pressure alarm may include circuit disconnection, exhalation valve driveline disconnection, endotracheal tube cuff leak, and a loose circuit connection. On 11/15/22 at 0848 hours, Resident 64 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 40 and the low pressure alarm was observed set at 15. Medical record review for Resident 64 was initiated on 11/15/22. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE]. On 11/15/22 at 1408 hours and 11/16/22 at 0808 and 1416 hours, Resident 64 PIP range was 41 to 46 and the low pressure alarm was set at 15. On 11/16/22 at 1421 hours, an observation of Resident 64's ventilator settings was conducted with RT 1. RT 1 verified how to check the ventilator settings. RT 1 verified Resident 64's average observed PIP on the ventilator was in the 40s and the low pressure alarm should be set 10 cmH2O below the PIP. RT 1 verified Resident 64's low pressure alarm was set at 15 instead of 30 based on the resident's average observed PIP. RT 1 stated the low pressure alarm was important because it would alert the staff if the resident was disconnected from the ventilator. On 11/16/22 at 1445 hours, an interview was conducted with RT 2. RT 2 verified the low pressure alarm should be set 5 to 10 cmH2O below the resident's observed PIP. Cross reference to F842. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 3 of 8 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was at 6.67% when the metoprolol (antihypertensive) medication for one of 19 final sampled residents (Resident 89) and one of one nonsampled resident (Resident 29) were not administered with food as per the manufacturer's specifications. This failure created the risk for complications and ineffective therapeutic effects of the medications. Residents Affected - Few Findings: According to Lexicomp.com (a professional resource or a nationally recognized drug information site for healthcare professionals), metoprolol tartrate medication should be taken with or immediately after food intake. a. During the medication administration observation on 11/17/22 at 0840 hours, the GT was clamped during the medication pass. LVN 1 administered metoprolol 10 mg to Resident 89 via GT. LVN 1 was asked when Resident 89 finished her breakfast. LVN 1 stated the GT feeding was turned off at around 0730 hours. LVN 1 further stated Resident 89 was in the RNA program eating at dining room and finished her breakfast meal at around 0800 hours. On 11/17/22 at 1015 hours, an interview was conducted with RNA 1. RNA 1 was asked when Resident 89 finished her breakfast meal. RNA 1 replied at around 0800 hours. Review of Resident 89's medical record was initiated on 11/17/22. Resident 89 was admitted to the facility on [DATE]. Review of the Order Summary report dated 10/30/22, showed to administer metoprolol tartrate 25 mg one tablet via the GT every 12 hours for high blood pressure and to hold if the systolic blood pressure less than 110 mmHg or heart rate less than 60 bpm. On 11/17/22 at 1205 hours, an interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant was asked regarding the administration instructions on the bubble pack of metoprolol to administer with or immediately after food intake. The Pharmacy Consultant stated the reason for administering with food was to prevent stomach upset and should be administered within 15 minutes after eating the food or with the food. b. On 11/17/22 at 0915 hours, Resident 29 pressed the call light to ask CNA 2 for snacks for her and her roommate. However, CNA 2 did not bring a snack for Resident 29 prior to the medication administration. During a medication administration observation on 11/17/22 at 0940 hours, LVN 1 administered the metoprolol medication to Resident 29 with cranberry juice. However, LVN 1 did not administer the medication with food as per the manufacturer's specification. On 11/17/22 at 1030 hours, CNA 1 was asked when did Resident 29 finished her breakfast meal. CNA 1 stated Resident 29 had her breakfast meal at around 0800 hours. Review of Resident 29's medical record was initiated on 11/17/22. Resident 29 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 4 of 8 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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 facility on [DATE] and readmitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the Order Summary report dated 10/30/22, showed to administer metoprolol tartrate 25 mg one tablet orally two times a day for hypertension (high blood pressure) and hold the medication if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 bpm. Residents Affected - Few On 11/17/22 at 1226 hours, an interview was conducted with LVN 1. LVN 1 was asked if she was aware the metoprolol medication should be administered with food or immediately after food intake. LVN 1 stated she was not aware of it. LVN 1 acknowledged the metoprolol medication was administered to Residents 89 and 29 approximately more than 40 minutes after both residents had eaten their breakfast meals. LVN 1 verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 5 of 8 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: Residents Affected - Some * The facility failed to ensure the can openers were in sanitary condition and free of food particles; the kitchen utensils had a smooth cleanable surface and were not worn out; the kitchen equipment was air dried and free of food particles; and the kitchen utensils were clean and free of food particles. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 11/15/22, showed 49 out of 95 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious (harmful) substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the FDA Food Code Annex 4-602.13, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During the initial tour of the facility's kitchen on 11/15/22 at 0808 hours, a concurrent observation and interview was conducted with the Dietary Aide 1. The following was identified: - A counter mounted can opener and a portable can opener were observed with brownish discoloration (metal part) and dry food residue. Dietary Aide 1 verified the findings. - A flipper spatula was observed to be chipped and worn off. The Dietary Aide 1 verified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 6 of 8 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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 finding and stated it was not safe to use because residual particles from the spatulas could be mixed with food. - A white blender was observed stored on the counter shelves. The blender's lid was still wet inside, and there was visible white food residue on the blender. The Dietary Aide 1 verified the finding and stated the equipment should have been stored dry. - A knife with a black handle was observed with dry, crusted food residue. The Dietary Aide 1 verified the finding and stated the knife should have been washed and cleaned properly to prevent food contamination. On 11/15/22 at 0855 hours, a concurrent observation and interview was conducted with the Food and Nutrition Services Director. The Food and Nutrition Services Director verified the above findings and stated everything should be washed and cleaned for safety, cross contamination, the possibility for food borne pathogen illnesses and infection control. 2. Review of the facility's P&P titled Kitchen Safety dated 2018 showed grease fires are common and dangerous. Vents in range hoods should be cleaned regularly, at least monthly, depending on extent of use. Know the locations of the nearest fire extinguisher and how to use them. Sides of floors around ranges should be cleaned daily. If the fire is on the stove, use the K (silver) fire extinguisher or pull the ansel system. On 11/17/22 at 1235 hours, an observation and concurrent interview was conducted with the Food and Nutrition Services Director. Black dirt residue was observed on the kitchen hood. The Food and Nutrition Services Director verified the finding and stated the kitchen staff were supposed to clean the hood weekly for sanitation purposes and infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 7 of 8 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 64) was complete and systematically organized. The facility failed to ensure Resident 64's respiratory rate and PIP were documented on the flow sheet after each ventilator check as per the facility's P&P. This had the potential for the resident's care needs not being met as their medical information was incomplete. Findings: Review of the facility's P&P titled Mechanical Ventilation Flowsheet (undated) showed services provided by the respiratory care provider must be documented properly in the resident's medical record. Each ventilator check will be recorded on the flow sheet with the following information as indicated, including the measured (respiratory) rate and PIP. On 11/15/22 at 0848 hours, Resident 64 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. Medical record review for Resident 64 was initiated on 11/15/22. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE]. On 11/16/22 at 1421 hours, an interview and concurrent medical record review was conducted with RT 1. Review of the Respiratory Evaluation dated 11/16/2022 at 0812 hours, failed to show documentation of Resident 64's measured respiratory rate and PIP. RT 1 verified the finding and stated the PIP was important because the ventilator high and low pressure alarms were set based on the PIP. Cross reference to F695. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 8 of 8