Health inspection·September 21, 2023

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 observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 20 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed was maintained in the lowest possible position in accordance with Resident 22's at risk for fall/injury care plan. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care. Findings: Medical record review for Resident 22 was initiated on 9/18/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's care plan titled At Risk for Fall/Injury dated 9/1/23, showed Resident 22 was at risk for fall/injury related to impaired vision, incontinence, and antihypertensive medications. In order to minimize Resident 22's risk for fall/injury the care plan showed the staff would provide the visual checks every two hours to assess the resident's needs and safety, instruct the resident to utilize the call light to ask for assistance, and maintain the bed in the lowest possible position. On 9/18/23 at 1139 hours, an observation and concurrent interview was conducted with CNA 1. Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. CNA 1 verified the findings and stated Resident 1 was a fall risk due to generalized weakness. On 9/18/23 at 1152 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. LVN 1 stated Resident 22 was a fall risk due to generalized weakness. LVN 1 verified Resident 1's care plan titled At Risk for Fall/Injury dated 9/1/23, showed Resident 22's bed was to be positioned in the lowest possible position. On 9/20/23 at 0917 hours, an observation and concurrent interview was conducted with CNA 1. Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. CNA 1 verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 2 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 20 final sampled residents (Resident 25) attained and maintained the highest practicable physical well-being. Residents Affected - Few * The facility failed to coordinate with the contracted hospice agency to provide the services to Resident 25 regarding the plan of care. This failure created the risk of not providing the appropriate and consistent care to Resident 25. Findings: Review of the facility's P&P titled Hospice Services dated 1/2017 showed the facility should ensure the hospice services meet professional standards and principles that apply to individuals providing services at the facility, and to the timeliness of the services. Further review of the P&P showed when a resident participates in the hospice program, a coordinated plan of care between the facility, the hospice agency and resident/responsible party should be developed and should include directives for managing pain and other uncomfortable symptoms. The care plan should be revised and updated as necessary to reflect the resident's status. The designated IDT member should be responsible for collaborating with hospice representatives and coordinating facility staff participating in the hospice care planning process for residents receiving these services. Review of the facility's Contract Agreement with Hospice A dated 7/1/17, showed the provider was responsible for copies of the initial assessment to be completed by Hospice A's RN and the ongoing assessments to be completed at each visit, the plan of care to be developed once the initial visit had been made, and the scheduling of visits and hours the resident was to be seen and rely on the facility to inform the hospice of additional needs. Medical Record review for Resident 25 was initiated on 9/20/23. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 25's physician's order dated 9/6/23, showed an order for a hospice evaluation with Hospice A. Review of Resident 25's physician's order dated 9/13/23, showed an order to admit Resident 25 to Hospice A. Review of Resident 25's plan of care failed to show all care plans were reviewed and signed by Hospice A. On 9/20/23 at 1547 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON was also the facility's Hospice Coordinator. The ADON verified there was no documentation of integration or coordination of plan of care from Hospice A for Resident 25. The ADON further stated Hospice A nurse should have reviewed and signed Resident 25's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 3 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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, medical record review, and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 22 and 72) remained free from accident hazards. * The facility failed to ensure Resident 22's bed was maintained in the lowest possible position as per the physician's order. Resident 22 was assessed to be at risk for falls. * The facility failed to accurately document Resident 72's history of falls on the Fall Risk Evaluation form resulting in an inaccurate fall risk score status post an unwitnessed fall. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Medical record review for Resident 22 was initiated on 9/18/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's physician's order dated 5/21/22, showed an order for Resident 22's bed to be positioned in the lowest possible position. Review of Resident 22's care plan titled At Risk for Fall/Injury dated 9/1/23, showed Resident 22 was at risk for fall/injury related to impaired vision, incontinence, and antihypertensive medications. Resident 22's risk for fall/injury care plan showed the staff would provide visual checks every two hours to assess the resident's needs and safety, instruct the resident to utilize call light to ask for assistance, and maintain bed in lowest possible position. On 9/18/23 at 1138 hours, Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. On 9/18/23 at 1139 hours, an observation and concurrent interview was conducted with CNA 1. Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. CNA 1 verified the findings and stated Resident 22 was a fall risk due to generalized weakness. On 9/18/23 at 1152 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. LVN 1 stated Resident 22 was a fall risk due to generalized weakness. LVN 1 verified Resident 22 had a physician's order for the bed to be positioned in the lowest possible position. On 9/20/23 at 0917 hours, an observation and concurrent interview was conducted with CNA 1. Resident 22 was observed lying in bed. Resident 22's bed was not positioned in the lowest possible position. CNA 1 verified the above findings. Cross reference to F656. 2. Review of the facility's P&P titled Record Content - Licensed Nurses Notes dated 1/04 showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 4 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 meaningful and informative notes shall be written by a licensed nurse to reflect the treatment, observations and assessments and other appropriate entries. Medical record review for Resident 72 was initiated on 9/18/23. Resident 72 was admitted to the facility on [DATE] and readmitted on [DATE]. Residents Affected - Few Review of Resident 72's fall history showed Resident 72 had an unwitnessed fall on 7/25/23. On 9/19/23 at 0945 hours, an interview and concurrent medical record review was conducted with RN 1. Review of Resident 72's Fall Risk Evaluation dated 7/25/23, under the category titled History of Falls, showed the numerical score of zero to indicate the resident had no fall within the last three months. The History of Falls category on the Fall Risk Evaluation form indicated a score of two showing the resident had one to two falls in the past three months. RN 1 verified the inaccuracy in the documentation and stated the score under the category of History of Falls should have reflected a score of two to account for Resident 72's fall on 7/25/23. The Fall Risk Evaluation score on 7/25/23, status post fall showed a total score of 13. However, adding the additional two points would equal a total Fall Risk Evaluation score of 15 where the higher the total fall risk score indicated the resident's higher risk for falls. On 9/20/23 at 0922 hours, an interview and medical record review was conducted with the ADON. The ADON verified Resident 72 had a fall on 7/25/23. The ADON further stated Resident 72's History of Falls category in the Fall Risk Evaluation form should have been scored a two to indicate Resident 72 had a fall within the past three months by including the fall that occurred on 7/25/23. The ADON stated accurate assessment of the Fall Risk Evaluation was important in order to provide proper interventions and recommendations to prevent future falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 5 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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, medical record review, and facility P&P review, the facility failed to ensure the equipment utilized to provide the residents with oxygen therapy was labeled and changed in accordance with the facility's P&P, for three of 20 final sampled residents (Residents 22, 23, and 87). Residents Affected - Few * The facility failed to ensure Resident 22's nasal cannula oxygen tubing and oxygen concentrator humidification bottle were labeled with the date when they were changed. * The facility failed to ensure Resident 23's nasal cannula oxygen tubing and oxygen concentrator humidification bottle were changed weekly and labeled with the date when they were changed. * The facility failed to ensure Resident 87's nasal cannula oxygen tubing was changed every seven days and as needed. These failures had the potential to result in negative health outcomes to the residents. Findings: Review of the facility's P&P titled Oxygen Concentrators dated 6/2017 showed pre-filled humidifiers are to be dated and replaced weekly or as needed. 1. Medical record review for Resident 22 was initiated on 9/18/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's care plan titled At Risk for Altered Breathing Pattern and Risk for Respiratory Distress related to CHF and history of COVID-19 revised 9/2023 showed to administer oxygen as ordered. Review of Resident 22's physician's orders showed an order to administer oxygen at 2 L/min via nasal cannula continuously. The oxygen rate may be titrated up to 5 L/min as needed to keep oxygen saturation level greater than 92%. On 9/18/23 at 1143 hours, an observation and concurrent interview was conducted with LVN 1. Resident 22 was observed lying in bed and receiving continuous oxygen at 3 liters per minute via a nasal cannula connected to an oxygen concentrator. An oxygen concentrator humidification bottle was observed attached to the oxygen concentrator and nasal cannula tubing. The nasal cannula tubing and humidification bottle were not labeled with the date they were changed as per the facility's P&P. LVN 1 verified the findings and was uncertain as to when the nasal cannula tubing and humidification bottle were last changed. LVN 1 stated the facility's P&P was to change the humidification bottle weekly and to label the humidification bottle with the date when it was changed. LVN 1 stated she would immediately discard Resident 22's nasal cannula oxygen tubing and humidification bottle and provide Resident 22 with new nasal cannula oxygen tubing and humidification bottle. 2. Review of Resident 23's medical record was initiated on 9/18/23. Resident 23 was readmitted to the facility on [DATE], from the hospital. Review of Resident 23's H&P examination dated 8/15/23, showed Resident 23 was admitted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 6 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 diagnoses of COVID and sepsis. Level of Harm - Minimal harm or potential for actual harm Review of Resident 23's MD Order Summary showed an order dated 8/13/23, for oxygen at 3 liters per minute via nasal cannula continuously to keep oxygen saturation above 92% for shortness of breath. Residents Affected - Few On 9/18/23 at 0922 hours, an observation was conducted on Resident 23. Resident 23 was observed with oxygen via nasal cannula on both nostrils. It was also observed the oxygen concentrator humidifier bottle was dated 9/10/23, while the cannula tubing did not have a date. During a concurrent observation and interview on 9/19/23 at 0752 hours, with the IP in Resident 23's bedside, Resident 23's oxygen concentrator humidifier bottle and cannula were observed to have a new label dated 9/18/23. The IP verified Resident 23's oxygen humidifier and cannula were changed yesterday, 9/18/23 in the evening and should have been changed on Sunday, 9/17/23, because both the oxygen humidifier bottle and cannula set should have been changed every week on Sundays. 3. Medical Record review for Resident 87 was initiated on 9/18/23. Resident 87 was admitted to the facility on [DATE]. Review of Resident 87's Order Summary Report dated 8/25/23, showed a physician's order dated 7/03/23, to administer oxygen at 2 L/min via nasal cannula continuous to keep oxygen saturation level above 92%. May titrate up to 5 L/min via nasal cannula to keep saturation level above 92% every shift for COPD (Chronic Obstructive Pulmonary Disease - a group of lung disease that block airflow and make it difficult to breathe). On 9/18/23 at 1152 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with LVN 11. Resident 87 was observed on his bed receiving oxygen at 2 L/min via nasal cannula. An oxygen concentrator (a portable medical device to provide a person extra oxygen) humidification bottle was observed attached to the oxygen concentrator and nasal cannula of Resident 87. The nasal cannula tubing was dated 8/27/23. LVN 11 verified the date written on the nasal cannula tubing was 8/27/23. On 9/20/23 at 0956 hours, a follow-up interview was conducted with LVN 11. LVN 11 was asked regarding the facility's practice on how often the oxygen tubing was changed. LVN 11 stated the oxygen tubing should be changed once a week, every Sunday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 7 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the nursing staff demonstrated the competencies and skill sets needed to provide safe nursing care to the residents. * CNA 6 failed to perform within their scope of practice when CNA 6 was observed turning off Resident 24's enteral feeding pump prior to performing ADL care. * The blood glucose test strips and control solution were not accurately tested with the Assure Platinum glucometer (device used to measure blood sugar levels). These failures had the potential to result in inadequate care and risk for adverse consequences for the residents. Findings: 1. Review of the facility document titled Certified Nursing Assistant Job Description, undated, showed the general duties and responsibilities for CNAs are to perform assigned duties in accordance with state, federal, and facility policies and procedures. Furthermore, specific requirements for CNAs showed they must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Medical record review for Resident 24 was initiated on 9/18/23. Resident 24 was admitted to the facility on [DATE]. On 9/18/23 at 1023 hours, a concurrent observation and interview with LVN 5 and CNA 6 was conducted. While interviewing LVN 5 regarding Resident 24 in Resident 24's room, CNA 6 was observed turning off Resident 24's enteral feeding pump. CNA 6 verified she turned off the enteral feeding pump because she needed to pull up Resident 24 and provide care. CNA 6 further stated she should have asked the license nurse to turn off the enteral feeding pump. LVN 5 verified CNA 6 turned off the enteral feeding pump and stated CNAs were not allowed to operate the enteral feeding pump. On 9/20/23 at 0834 hours, an interview with CNA 7 was conducted. CNA 7 stated CNAs or RNAs were not supposed to touch the enteral feeding pump. CNA 7 also stated the RNs or LVNs were the designated staff to operate the enteral feeding pump. On 9/20/23 at 0840 hours, an interview with the DON was conducted. The DON verified the CNAs could not turn on or off the enteral feeding pump and were to notify their charge nurse. In addition, the DON also stated CNAs were not to operate the machine regardless if a license nurse was present in the resident's room and stated only the RNs and LVNs could operate the enteral feeding pump. 2. Review of the facility document titled Assure Platinum glucometer, undated, showed to use the control solution within 90 days (three months) of first opening. It is recommended that you write the date of opening on the control solution bottle label (date opened) as a reminder to dispose of the opened solution after 90 days. Review of the facility document titled Assure Platinum Test Strips dated 1/21 showed for storage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 8 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 0726 Level of Harm - Minimal harm or potential for actual harm and handling, when first open the vial, to write the date on the vial label and use the test strips within three months of first opening the vial. On 9/19/23 at 1121 hours, an inspection of Medication Cart 3 and concurrent interview was conducted with LVN 9. The following was observed: Residents Affected - Few - an opened vial of Assure Platinum blood glucose test strips 30 counts with an open date of 9/18/23. - an opened box of Assure Dose control solution with an open date of 7/12/23. Review of the facility document titled Daily Quality Control Record for September 2023 showed the Assure Platinum glucometer quality control check was completed from 9/6/23 through 9/19/23. The Daily Quality Control Record for the blood glucose test strips opened on 9/18/23, showed the documented use by date was 12/22/24, more than 15 months after the opened date instead of 90 days after the opened date as per the manufacturer's instructions. For the control solution opened on 7/12/23, the use by date documented was for 1/3/24, more than six months after the opened date instead of 90 days after the opened date as per the manufacturer's instructions. LVN 9 verified the use by date on the Daily Quality Control Record was the expiration date of the blood glucose test strips and the control solution. On 9/19/23 at 1209 hours, a concurrent observation and interview was conducted with the DON and RN 1. RN 1 stated the test strips and control solution were good until the expiration date and the log was documented by the night shift. RN 1 and the DON acknowledged the documented use by date was not according to the manufacturer's instructions. RN 1 stated the LVN from the SNF pharmacy came to check their medication cart once a month and must have missed that the test strip and control solution were documented with the original expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 9 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one nonsampled resident (Resident 27) when Resident 27's losartan (blood pressure medication) was not available on 9/15 and 9/16/23. This failure resulted in Resident 27 not receiving the blood pressure medication for two days, which had the potential to result in poor health outcomes to the resident. Findings: Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy dated 4/2008 showed repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: reorder medication five days in advance of need to assure an adequate supply is on hand. Medical record review for Resident 27 was initiated on 9/18/23. Resident 27 was admitted to the facility on [DATE], with diagnoses including essential hypertension (high blood pressure). Review of Resident 27's Order Summary Report dated 9/19/23, showed a physician's order dated 1/24/23, for losartan potassium oral tablet 100 mg one table orally in the morning for hypertension. Review of Resident 27's MAR for September 2023 showed to see LVN 2's progress notes for losartan potassium for 9/15 and 9/16/23. Review of Resident 27's Orders - Administration Note dated 9/15/23 and 9/16/23, showed a progress note for each day stating the losartan potassium was not available. On 9/20/23 at 0832 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 27's medication ran out on 9/15/23. On 9/20/23 at 0855 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated he called the pharmacy for the refill on 9/15/23; however, he verified he did not fax a medication order form to the pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 10 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the side effect monitoring of blood thinner medications for two nonsampled residents (Residents 10 and 68). This failure had the potential to cause negative outcomes for Residents 10 and 68. Residents Affected - Few Findings: Review of the facility's P&P titled Adverse Consequences and Medication Errors revised April 2014 showed the residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. 1. Medical record review of Resident 10 was initiated on 9/19/23. Resident 10 was admitted to the facility on [DATE], from the acute care hospital. Review of Resident 10's H&P examination dated 7/9/23, showed Resident 10 had a history of medical diagnoses of carotid stenosis and CVA. Review of Resident 10's care plan titled At Risk for Bleeding dated 7/7/23, showed Resident 10 was on anticoagulant therapy of Plavix (blood thinner medication) with the following interventions: * Observe for presence of bleeding in urine, stool, nosebleed, emesis, etc; * Observe for any complaints of pain of the abdomen, headaches, etc; * Notify MD of coffee-ground color emesis; and * Notify MD of any bleeding episodes or any significant change in general condition, presence of bruises, etc. Review of Resident 10's MD Order Summary showed an order dated 7/7/23, for Plavix oral tablet 75 mg one tablet by mouth one time a day for CVA prophylaxis. However, the order summary did not show any orders to monitor for side effects of bleeding for Plavix. Review of Resident 10's MAR and TAR from 9/1/23-9/18/23, showed Resident 10 had been receiving Plavix daily at 0900 hours, but there was no documented evidence of monitoring for the side effects of bleeding. On 9/19/23 at 1143 hours, an interview was conducted with LVN 10. LVN 10 stated the medications, such as Eliquis, aspirin, warfarin, Lovenox, and Plavix were to be monitored for side effects of bleeding. LVN 10 also verified there was no MD order to monitor for bleeding and no documented evidence of monitoring for bleeding, and further stated there should be one. 2. Medical record review of Resident 68 was initiated on 9/18/23. Record review showed Resident 68 was readmitted to the facility on [DATE], from the acute care hospital. Review of Resident 68's H&P examination dated 7/13/23, showed Resident 68 had a medical history of HTN, osteoporosis, generalized weakness, and dementia. It also showed Resident 68 went to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 11 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 hospital for a placement of feeding tube. Level of Harm - Minimal harm or potential for actual harm Review of Resident 68's MDS dated [DATE], showed Resident 68 required extensive assistance and/or total dependence on staff with ADL care as well as the use of wheelchair for mobility. Residents Affected - Few Review of Resident 68's care plan titled At Risk for Bleeding dated 7/13/23, showed Resident 68 was on Lovenox (blood thinner medication) injection with the following interventions: * Observe for signs and symptoms of bleeding, such as tarry stools, bleeding gums, epistaxis, hematuria, hemoptysis, vomiting, pain, and swelling of joins, elevated temperature, easy bruisability, and notify MD for any; * Observe injection site for bleeding, pain/tenderness, and notify MD for any; and *Observe for signs and symptoms of adverse reactions from medication, such as fever, pain, paralysis, confusion, shortness of breath, elevated LFT, persistent bleeding or oozing from mucus membranes or wounds, and notify MD for any. Review of Resident 68's MD Order Summary showed an order dated 7/13/23, for Enoxaparin Sodium Solution (Lovenox) 40 mg/0.4 ml to be injected subcutaneously one time a day for blood clotting prevention. Further review of Resident 68's MD Order Summary Report did not show any orders to monitor for side effects of bleeding for Lovenox. Review of Resident 68's MAR and TAR from 9/1/23-9/18/23, showed Resident 68 had been receiving Lovenox daily at 0900 hours, but there was no documented evidence of monitoring for the side effects of bleeding. On 9/19/23 at 1008 hours, an interview was conducted with LVN 5. LVN 5 stated they monitored for bleeding by looking at bruising on the skin and blood in the urine and stool. LVN 5 verified there was no MD order to monitor for side effects of bleeding nor documented evidence of monitoring the side effects of bleeding, and further stated there should be one. On 9/19/23 at 1008 hours, an interview was conducted with the Assistant DON. The Assistant DON stated there should have an MD order to monitor for the side effects of bleeding and documented evidence of monitoring the side effects of bleeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 12 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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, facility document review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 43) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 43 who had diagnoses including dementia (a disorder which causes a progressive decline in memory and behavior that affects the ability to perform everyday activities) was prescribed quetiapine fumarate (Seroquel, an antipsychotic medication) for psychosis manifested by striking out at staff. There was no documented diagnosis of psychosis prior to starting the quetiapine fumarate medication. * The facility failed to ensure documentation of evaluation and rationale for increasing Resident 43's prescription of Seroquel from 12.5 mg once a day to 12.5 mg two times a day on 10/4/22, and from 12.5 mg two times a day to 50 mg two times a day on 1/30/23. * The facility failed to ensure the non-pharmacological interventions were implemented prior to administering and increasing Resident 43's Seroquel. * The facility failed to ensure documentation of clinical rationale for a GDR clinical contraindication. * The facility failed to ensure the MDS was accurately documented for Resident 43's Seroquel dose. These deficient practices had the potential to place the residents at risk for receiving unnecessary medications and increased risk of serious medication adverse reactions. Findings: Review of the FDA black box warning for prescribing Seroquel (quetiapine fumarate) showed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for elderly patients with dementia-related psychosis. Review of the facility's P&P titled Psychotropic Drug Treatment revised 9/2017 showed in part, the purpose of this procedure is to provide psychotropic drug treatment for a resident with a specific condition as diagnosed and documented in the clinical record. When their use is indicated, the facility should use the least restrictive alternative for the least amount of time and document on-going evaluation of the need for psychotropic drug treatment .Medication use is not the sole approach for behavioral intervention. Other non-pharmacological interventions will be identified and implemented on the plan of care .Before initiating or increasing an antipsychotic medication, the target behavior must be clearly and specifically identified and documented. Monitoring must ensure that the behavioral symptoms are not due to environmental stressors that can be addressed to improve the symptoms and not due to psychological stressors alone that can be addressed to improve or resolve the symptoms. Additionally, the P&P stated for dose reductions, clinically contraindicated means that a resident need not undergo a GFR if the resident's physician provides justification why the continued use of the drug and the dose is clinically appropriate .the information must be a part of the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 13 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 clinical record. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 43 was initiated on 9/19/23. Resident 43 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 43's Hospitalist Discharge Summary from the acute care hospital dated 8/27/22, showed Resident 43 had a diagnosis of dementia. The Discharge Summary note showed Resident 43's caretaker was unable to care for the patient as she is healing from an injury and thus skilled nursing was found for the placement. Resident 43 was started on low-dose Seroquel to help with sleep with her usual home medications for chronic cough. Review of Resident 43's Discharge Medication List from the acute care hospital dated 8/27/22, showed Resident 43 was discharged from the acute care hospital with the medications including Seroquel 25 mg 1/2 tablets (12.5 mg) by mouth nightly (one time a day). Review of Resident 43's Physician Order Report showed an admission order dated 8/27/22, for quetiapine 25 mg 1/2 tablet (12.5 mg) oral for psychosis manifested by striking out at staff at bedtime. * Review of Resident 43's H&P examination dated 8/29/22, showed Resident 43 had a diagnosis of dementia and was alert but demented; however, the document failed to show a justification for Resident 43's Seroquel medication order. The H&P examination failed to show a diagnosis of psychosis for the use of Seroquel. Review of the Physician and Telephone Orders dated 10/4/22, showed a telephone order by NP 1 to change to the quetiapine dosage to 25 mg 1/2 tablet (12.5 mg) by mouth every 12 hours for psychosis manifested by striking out at staff. Review of Resident 43's Psychiatry Initial Eval dated 11/26/22, showed Resident 43 was on Seroquel 12.5 mg every 12 hours for psychosis manifested by striking out at staff. Seroquel was increased on 10/4/22, because of episodes of trying to get out of bed to go home and calling out for people due to fear of being alone. The family member said she wanted the current dose continued because it helped to calm the resident. The evaluation also showed the family member said Seroquel was originally prescribed prior to admission for insomnia (difficulty sleeping). Review of Resident 43's Physician Order Report from January 2023 showed the following: - The dose of quetiapine ordered on 10/4/22, was discontinued on 1/30/23. - The Physician and Telephone Orders dated 1/30/23, showed an order by NP 1 for Seroquel 50 mg by mouth two times a day for psychosis manifested by striking out at staff. The dose was four times more than the previous dose taken by Resident 43. Additionally, the Physician and Telephone Orders showed an order by NP 1 on 2/3/23 (four days after), to discontinue the Seroquel 50 mg dose and changed the prescription to Seroquel 25 mg by mouth two times a day for psychosis manifested by striking out at staff. * However, review of the Psychotherapeutic Drug Summary for Resident 43 dated 8/27/22 through 2/28/23, showed no episodes of Resident 43 striking out at staff during the time period. Further review of Resident 43's medical record failed to show available documentation of the justification and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 14 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 clinical indication for the increase doses of Seroquel prescribed on 10/4/22, and 1/30/23. Level of Harm - Minimal harm or potential for actual harm * Review of Resident 43's Physician Order Reports dated October 2022 through March 2023 failed to show an order for non-pharmacological interventions related to the use of the psychotropic medication. Residents Affected - Few * Further review of Resident 43's medical record failed to show any documented evidence related to non-pharmacological interventions implemented. * Review of Resident 43's informed consents showed an informed consent for the increase of Seroquel on 10/4/22. However, for the increase of the Seroquel dose on 1/30/23, to 50 mg, an informed consent was not obtained until 2/5/23, six days after the increase of the dose. * Review of Physician 1's progress notes for Resident 43 dated 6/23/23, showed to continue Seroquel as prescribed and the GDR not clinically indicated. However, Physician 1 failed to document the clinical rationale for the clinical contraindication of a GDR. * Review of the MDS dated [DATE], showed a GDR had been attempted on 2/3/23. However, further review of Resident 43's medical record failed to show any other physician or pharmacy notes related to a GDR. On 9/20/23 at 1110 hours, an interview was conducted with LVN 9. LVN 9 stated Resident 43 was nice and quiet. LVN 9 stated sometimes Resident 43 was confused but did not yell out. On 9/20/23 at 1126 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 43 would start yelling when she needed something and would call for the bathroom, if she was hungry, or needed to be changed. CNA 2 stated Resident 43 always had a reason to scream, if not, she was sleeping and fine. On 9/20/23 at 1157 hours, an interview was conducted with Family Member 2. Family Member 2 stated Resident 43 was started on Seroquel in the hospital and worked well because Resident 43 was nervous and could not sleep. Family Member 2 stated at one point, the Seroquel dose was too much, and Resident 43 had trouble eating her meals, so they had to lower the dosage. On 9/21/23 at 0836 hours, an interview was conducted with RN 1, the ADON, and DON. The DON stated before Resident 43 was admitted , she was put on the Seroquel for sleep; and they tried to discontinue it, but Resident 43's family member insisted Resident 43 to take the medication. The DON stated the family member insisted and claimed Resident 43 was taking the Seroquel at home. The ADON verified there were no order or documentation of implementation for nonpharmacological interventions since admission 8/2022 for Resident 43, and RN 1 verified she inputted the orders for the nonpharmacological interventions one year later 8/2023. On 9/21/23 at 0927 hours, an interview was conducted with the MDS nurse. The MDS nurse verified there was no GDR performed for Resident 43 and the date of 2/3/23, documented on the MDS was inaccurate. The MDS nurse stated there was no note for a GDR recommendation. On 9/21/23 at 1034 hours, an interview was conducted with NP 1. NP 1 stated his process for prescribing psychotropic medications upon admission was to look at the residents' past medical history, past behavior during and after hospitalization, speak to the family members, and evaluate available (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 15 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 records. NP 1 stated Resident 43 had disorganized thought and dementia and had dangerous behavior to herself, which was getting out of the wheelchair. NP 1 stated he diagnosed Resident 43 with psychosis upon admission. NP 1 stated to increase a dose, the resident would need to be reevaluated in person, and he would review the last 24-72 hours of behaviors and write a progress note. NP 1 stated he e-faxes his notes to the facility and could not provide reasoning as to why there were no progress notes available for the increase of the Seroquel doses. NP 1 verified the informed consent should be done within 72 hours prior to increasing the dose of the medication. * Further medical record review for Resident 43 showed no progress notes available to show a diagnosis of psychosis for Resident 43 until the psychiatric evaluation by Physician 1 on 11/26/22. There were no progress notes available from NP 1 until 9/20/22, which additionally, did not mention any diagnosis of psychosis for Resident 43. On 9/21/23 at 1154 hours, an interview was conducted with Physician 1. Physician 1 stated he submited a rationale for GDR not indicated on a form which clarified the clinical rational for clinical contraindication and did not know what happened to the form. Physician 1 stated his progress note should be accompanied by his GDR form and would follow up with the staff. On 9/21/23 at 1552 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD stated Physician 1 had emailed the GDR form to her; however, the document was blank. The SSD stated she asked Physician 1 if he had filled out the form, and Physician 1 stated no. The SSD verified there was no document explaining why a GDR was clinical contraindicated for Resident 43's dose of Seroquel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 16 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 13.79%. Residents Affected - Few * The facility failed to administer eyedrops as per the facility's P&P and aspirin (blood thinner) chewable tablets as chewable to Resident 28. * The facility failed to administer aspirin chewable tablets as chewable for Resident 27. * The facility failed to administer Metamucil (fiber supplement) in accordance with the pharmacy label to Resident 94. These failures had the potential to negatively affect the residents' health. Findings: 1. Review of the facility's P&P titled Specific Medication Administration Procedures - IIB6: Eye Drop Administration dated 4/2008 showed the procedure as follows: - Pull the lower eyelid down and away from the eyeball to form a pocket. - Hold the dropper tip directly over the eye, taking care to avoid touching the eye or eyelid. - Instruct resident to look upward, and place one drop into the pocket, continuing to hold the eyelid for a moment to allow the medication to distribute. On 9/18/23 at 0818 hours, an observation of Resident 28's medication administration was conducted with LVN 1. a. LVN 1 was observed to instill one drop of Artificial Tears (lubricant) to each of Resident 28's eyes by lifting the top of the eyelid and applied the drop directly onto each eye. Medical record review for Resident 28 was initiated on 9/18/23. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's Order Summary Report dated 9/19/23, showed a physician's order dated 3/26/23, for Artificial Tears ophthalmic solution (carboxymethylcellulose sodium) one drop to both eyes four time a day for dryness of the eyes. b. While LVN 1 was preparing Resident 28's morning medications, Resident 28's aspirin medication bottle was observed showing the medication was chewable aspirin 81 mg tablet. LVN 1 was observed to administer Resident 28's morning medications; however, upon administration of the aspirin tablet, LVN 1 did not instruct Resident 28 to chew the medication. Review of Resident 28's Order Summary Report dated 9/19/23, showed a physician's order dated 11/27/21 for aspirin tablet 81 mg one tablet by mouth in the morning for CVA (stroke) prophylaxis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 17 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 9/18/23 at 1451 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she did not administer the eyedrops as per the facility's P&P and verified she did not administer the aspirin to Resident 28 as chewable. 2. On 9/18/23 at 0853 hours, an observation of Resident 27's medication administration was conducted with LVN 3. While LVN 3 was preparing Resident 27's morning medications, Resident 27's aspirin medication bottle was observed showing the medication was a chewable aspirin 81 mg tablet. LVN 3 was observed to administer Resident 27's morning medications; however, upon administration of the aspirin tablet, LVN 3 did not instruct Resident 27 to chew the medication. Medical record review for Resident 27 was initiated on 9/18/23. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's Order Summary Report dated 9/19/23, showed a physician's order dated 1/24/23, for aspirin tablet chewable 81 mg one tablet by mouth one time a day for CVA (stroke) prophylaxis. On 9/18/23 at 1506 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified she did not administer the aspirin to Resident 27 as chewable. 3. On 9/18/23 at 0916 hours, an observation of Resident 94's medication administration was conducted with LVN 5. While LVN 5 was preparing Resident 94's morning medications, Resident 94's Metamucil bubble pack with a pharmacy label was observed and showed the following: to take this product at least two hours before or two hours after other medications. However, LVN 5 administered the Metamucil together with Resident 94's other morning medications. On 9/18/23 at 1506 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 acknowledged the pharmacy alert label on the Metamucil bubble pack and acknowledged the medication was not given in accordance with the pharmacy label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 18 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to ensure the proper storage temperature of medications in Medication room [ROOM NUMBER]. The temperature of Medication room [ROOM NUMBER] was 81 degrees F; however, the medications stored in Medication room [ROOM NUMBER] showed to store at the controlled room temperature between 68 to 77 degrees F. This failure posed the risk for administration of deteriorated medication. * The facility failed to maintain the acceptable temperature of the medication refrigerator in Medication rooms [ROOM NUMBERS]. The temperatures of the medication refrigerators were below 36 to 46 degrees Fahrenheit. This failure posed the risk for administration of deteriorated medication. * The facility failed to dispose of the expired and discontinued medications and supplies in Medication Carts 1, 2, 3, and 4. This failure had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the medications administered orally were stored separate from the externally used medications in Medication Cart 2. This failure posed the risk for medication errors. Findings: Review of the facility's P&P titled Medication Storage In The Facility dated 4/2008 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. 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, and reordered from the pharmacy if a current order exists. 1. On [DATE] at 1556 hours, an inspection of Medication room [ROOM NUMBER] and concurrent interview was conducted with LVNs 5 and 7, and RN 2. The following was observed: a. A thermometer on the wall showed the temperature reading of 81 degrees F. Review of the facility document titled Medication Room Daily Temperature Log for 2023 showed to check the medication room temperature log daily, the temperature should be between 59 - 86 degrees F. The Log showed for August and [DATE], the temperature of Medication room [ROOM NUMBER] was at 79 - 81 degrees F. Multiple medications for different residents were observed in a cabinet. The medications inside the cabinet showed to store the medication at a controlled room temperature 68 to 77 degrees F. For example, an unopened box of levalbuterol inhalation solution 0.63 mg/3 ml (medication which relaxes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 19 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 muscles in the airways), showed an intruction to store the medication at 68 to 77 degrees F. Other medications in the cabinet also showed the same storage instructions, including an unopened box of budesonide inhalation suspension 0.5 mg/2 ml (steroid which decreases inflammation in the lungs), an unopened box of enoxaparin sodium injections 40 mg/ 0.4 ml (blood thinner), and multiple bubble packs (a package of individually sealed tablets in which an individual pushes the medication through the foil to take the medication) of medications. In addition, Medication room [ROOM NUMBER] was observed to store three E-Kits containing medications such as one ampule of epinephrine 1 mg/ml (emergency medication to treat severe allergic reactions) and three vials of Rocephin 1 gm/vial (antibiotic). RN 2 verified the above findings and acknowledged the temperature for Medication room [ROOM NUMBER] was not within the manufacturer's recommendations for medication storage. b. During an inspection on [DATE] at 1556 hours, a thermometer in the medication refrigerator showed a temperature reading of 30 degrees F. The freezer portion of the medication refrigerator was surrounded with a layer of white frost. Multiple medications were observed inside the refrigerator. The medications inside the refrigerator showed to store the medications at 36 to 46 degrees F. For example, an unopened box of tuberculin purified protein derivative 5 TU/0.1 ml (medication used to aid with the diagnosis of tuberculosis, a respiratory disease) showed an instruction to store the medication between 36 to 46 degrees F. Review of the facility document titled Refrigerator Temperature Log for 2023 showed documentation of the refrigerator temperatures within range (36 to 46 degrees F) for the year, including the morning of [DATE] (inspection day), which was 38 degrees F. LVN 5 verified the above findings and acknowledged the temperature for the medication refrigerator was not maintained within the manufacturer's recommendations for medication storage. 2. On [DATE] at 0821 hours, an inspection of Medication room [ROOM NUMBER] and concurrent interview was conducted with RN 1. The following was observed: A thermometer in the medication refrigerator showed the temperature reading of 32 degrees F. Multiple medications were observed inside the refrigerator with the instructions to store the medications at 36 to 46 degrees F. Review of the facility document titled Refrigerator Temperature Log for 2023 showed documentation of the refrigerator temperatures were within range (36 to 46 degrees F) from the beginning of the year to the review date. The log showed in the morning of inspection date of [DATE], the temperature was 40 degrees F. RN 1 verified the above findings and acknowledged the temperature for the medication refrigerator was not maintained within the manufacturer's recommendations for medication storage. 3. On [DATE] at 0849 hours, an inspection of Medication Cart 1 and concurrent interview was conducted with RN 1. RN 1 stated the nurses checked the carts every Friday. The following was observed: - 12 hyperdermic needles with an expiration date of 6/2020 - one safety needle with an expiration date of 3/2020 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 20 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 - one open tegaderm (wound dressing) taken out of the package Level of Harm - Minimal harm or potential for actual harm - one open sterile bandage roll pack - one nail cutter Residents Affected - Some RN 1 verified the above findings. 4. On [DATE] at 1043 hours, an inspection of Medication Cart 2 and concurrent interview was conducted with LVN 8. The following was observed: - one 12 tablet bubble pack of APAP/COD #3 300/30 mg (pain medication) with an expiration date of [DATE]. - a box of hydrocortisone acetate suppositories 25 mg (used to treat inflammation in the rectum/anus) for rectal administration stored together with a box of albuterol sulfate inhalation aerosol (medication which helps with breathing) 90 mcg. - a box of saline laxative enema stored together with docusate sodium (stool softener) and Pro-Stat nutritional supplement. LVN 8 verified the above findings. 5. On [DATE] at 1121 hours, an inspection of Medication Cart 3 and concurrent interview was conducted with LVN 9. The following was observed: - one 28 tablet bubble pack of Tramadol 50 mg with an expiration date of [DATE]. LVN 9 verified the above finding. 5. On [DATE] at 1239 hours, an inspection of Medication Cart 4 and concurrent interview was conducted with RN 1. The following was observed: - two Lifesaver Adult Manual Resuscitator with Mask and Flow Diverter with an expiration date of [DATE]. - five povidone-iodine swab sticks with an expiration date of [DATE]. - one IV start kit with an expiration date of [DATE]. - one smallbore extension set with an expiration date of [DATE]. - one opened box of alcohol prep pads with an expiration date of 09/21. - one box probe covers with an expiration date of [DATE]. - three respvac yankauer suction handle with an expiration date of [DATE]. - five Lubricating jelly packets with an expiration date of 6/20. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 21 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 - four vitamin A&D ointment packets with an expiration date of 8/22. Level of Harm - Minimal harm or potential for actual harm - seven packets of triple antibiotic ointment with an expiration date of 12/22. - seven packets of skin protectant with an expiration date of 8/22. Residents Affected - Some - two CHG wipes packets with an expiration date of 5/21. - one saline flush with an expiration date of [DATE]. RN 1 verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 22 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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: Residents Affected - Some * The facility failed to ensure the kitchen staff performed hand hygiene during dishwashing. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the microwave oven was clean and free of food particles. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. 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 Resident Census and Conditions of Residents completed by the DON dated 9/18/23, showed 82 of 97 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, 2-301, when to Wash, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment, and utensils, and unwrapped single-service and single use articles; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. On 9/20/23 at 0842 hours, an observation with concurrent interview was conducted with Dietary Aide 1 during dishwashing. Dietary Aide 1 was observed wearing gloves and scraping food from the dirty plates and meal trays for dishwashing; and while wearing the same pair of gloves, Dietary Aide 1 was observed handling the clean dishes. Dietary Aide 1 then touched the clean plates and cups with the same gloves. Dietary Aide 1 verified the findings and stated he rinsed his gloves prior to touching the clean dishes. On 9/20/23 at 0845 hours, the above findings were verified with the Dietary Supervisor Assistant. The Dietary Supervisor Assistant stated Dietary Aide 1 should have performed hand hygiene and changed his gloves to avoid cross contamination. 2. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and 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. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. During the initial kitchen tour on 9/18/23 at 0852 hours, a concurrent observation and interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 23 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 was conducted with the Dietary Supervisor. A heavy-duty blender was observed stored on the counter shelves and was still wet and with visible water inside. The Dietary Supervisor verified the above findings and stated it was supposed to be air dried. 3. 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 kitchen tour on 9/18/23 at 0835 hours, an observation and concurrent interview was conducted with the Dietary Supervisor. The microwave oven on the counter shelves used for warming food for the residents was observed with dry, crusted, whitish food residue on the interior part of the microwave door. The Dietary Supervisor verified the findings and stated it should have been cleaned daily by the dietary staff. 4. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. During the initial kitchen tour on 9/18/23 at 0850 hours, a concurrent observation and interview was conducted with the Dietary Supervisor. Two dark brown, one white, and blue cutting boards were observed with deep groves, marred, discolored, and fuzzy. The Dietary Supervisor verified the findings and stated they should have been replaced, cleaning would not be sufficient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 24 of 25 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure garbage was properly stored in three of four garbage dumpsters. The failure had the potential to attract pest/rodents that carried diseases. Residents Affected - Some Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 9/18/23 at 0906 hours, an observation with concurrent interview with the Maintenance Supervisor was conducted. Three of four facility's outside garbage dumpsters were observed to have the lids partially propped open by garbage, preventing the lids from fully closing. The Maintenance Supervisor verified the findings. The Maintenance Supervisor stated he had to push the trash down to close the lids and it was important to keep the lids completely closed due to infection control purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056145 If continuation sheet Page 25 of 25