Health inspection·October 29, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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 provide reasonable care for the protection of the resident's personal property from loss or theft for one of 19 sampled residents (Resident 39). Resident 39's cabinet was locked with a chain and a padlock; however, when she was transferred to another room, the facility failed to ensure the chain and padlock were placed in the resident's cabinet in the new room. This resulted in Resident 39 feeling upset and stressed about her personal belongings, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Personal Property revised 9/12 showed upon request, the facility shall provide or allow the resident to place a lock, chain or other security device on his/ her night stand, bed side table, and/or closet door as appropriate. On 10/26/21 at 1000 hours, during the initial tour of the facility, an interview was conducted with Resident 39. Resident 39 stated when she was admitted to the facility, she placed a chain and lock to her cabinet because she did not want to lose her belongings. Resident 39 stated when she came back to the facility from an out on pass leave(therapeutic leave, a non-medical visit outside the facility), she was told she needed to be transferred to another room. Resident 39 stated the SSD asked for the key to her cabinet lock so they could transfer her belongings to the other room. Resident 39 stated the SSD told her she could not lock her cabinet. Resident 39 stated she felt upset and stressed about not being able to lock her cabinet where she kept her personal belongings. Medical record review for Resident 39 was initiated on 10/26/21. Resident 39 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 39 was cognitively intact. On 10/28/21 at 1613 hours, an interview was conducted with the SSD. The SSD stated she only knew Resident 39 locked her cabinet with a chain and padlock when they were about to transfer her belongings to another room. The SSD stated she asked Resident 39 for the key to her padlock and gave the key to the Maintenance Director. The SSD stated it was the Maintenance Director who opened the cabinet and transferred the resident's belongings to the new room. The SSD stated they did not place Resident 39's chain and padlock in the dresser in the new room because the Maintenance Director stated it was against facility code. The SSD stated she knew Resident 39 was upset when she was not allowed to use her chain and lock on her new cabinet. When asked if she documented this incident, the SSD stated she did not document because she did not want to make a big deal out of it. On 10/28/21 at 1656 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated when Resident 39 came back from out on pass, he had to transfer the resident's belongings to another room. The Maintenance Director stated he noticed Resident 39 used a medium-sized chain and a heavy pad lock to lock her cabinet. The Maintenance Director stated it was his personal opinion that it was not safe for the resident to use this type of chain and pad lock. The Maintenance Director stated it was a safety issue because the resident might lose the key, and they would have to cut the chain or the padlock. The Maintenance Director stated he told the SSD it was not safe for Resident 39 to use the chain and lock. The Maintenance Director stated he did not offer Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 2 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 39 another type of lock to secure her cabinet. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 3 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered in accordance with the standards of practice for one of the nonsampled resident (Resident 48). * Resident 48's polyethylene glycol (laxative medication) was not administered in a timely manner. This failure had the potential for medication errors. Findings: Review of facility's P&P titled Medication Administration, revised 07/13, under the section Procedures, showed Medication must not be prepared in advance and must be administered within one hour before and after administration time per the physician's order. On 10/28/21 at 0749 hours, a medication administration observation was conducted for Resident 48 with LVN 2. LVN 2 withheld Resident 48's polyethylene glycol 3350 powder 17 grams, 1 scoop by mouth one time a day for bowel management. LVN 2 was stated she had to check the medications later. Review of the Order Summary Report for October 2021, showed a physician's order dated 10/28/21 to administer polyethylene glycol 3350 powder 17 gm/scoop, 1 scoop by mouth one time a day for bowel management and hold for loose stool. Pour the powder into a cup containing 8 ounces (240 milliliters) of water, juice, soda, coffee, or tea. Stir to dissolve the powder. Review the Medication Administration Record dated 10/1/21-10/31/21, showed, Resident 48's polyethylene glycol was not administered at 0900 hours. On 10/28/21 at 1008 hours, a follow-up interview was conducted with LVN 2. When asked about Resident 48's polyethylene glycol medication, LVN 2 acknowledged she had not administered the medication yet since she was not aware of the dose. LVN 2 acknowledged she was running late in giving Resident 48's medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 4 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure labeling and dating of foods in the refrigerator and open storage area used for resident food. * The facility failed to air dry equipment. * The facility failed to ensure the kitchen utensils had a smooth 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 facility dated 11/2/21, showed 90 of 92 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Receiving and Storage of Cold Foods dated 2018, showed all the perishable food items purchased by the department of food and dining services will be stored properly. All open food items will have an open date and use-by-date per manufacturer's guidelines. On 10/26/21 at 0744 hours, during the initial tour of the kitchen conducted with DSS, the following were observed: - a bag of cheese inside the refrigerator was observed opened and undated; and - two containers of granulated garlic, and cinnamon sticks stored in the open storage area were observed opened with illegible opened dates. The DSS verified the findings and stated the food items should have been properly labeled and dated with received and open dates. 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 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. On 10/28/21 at 1205 hours, during a trayline observation, several divided plates were observed stacked on top of each other and were observed wet. The DSS verified the finding and stated the plates should have airdried as they pass through the dishwashing machine. The DSS stated and the staff should have waited for the plates to be airdried before placing them in the trayline area. 3. 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 substances or impart colors, odors, or tastes to food and under normal use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 5 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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. On 10/28/21 at 0740 hours, an observation and concurrent interview was conducted with the DSS. Two flipper spatulas were observed to be worn off and melted. The DSS verified the findings. The DSS stated these may have melted when used in the grill and should have been discarded. Event ID: Facility ID: 056151 If continuation sheet Page 6 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in two of two garbage dumpsters. The lid of the facility's garbage dumpsters were left open. This failure had the potential to harbor pests or rodents which carry diseases. Residents Affected - Some Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. Review of the facility's P&P titled Food-Related Garbage and Rubbish Disposal revised 12/2014, showed outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. On 10/28/21 at 0740 hours, an observation and concurrent interview was conducted with the DSS. The two garbage dumpsters located outside of the facility adjacent to the kitchen were observed with the lids propped open. The DSS verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 7 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Handwashing/Hand Hygiene rrevised August 2019 showed showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation - after contact with resident's intact skin. Residents Affected - Many On 10/27/21 at 0854 hours, a wound care observation for Resident 26 was conducted with LVN 1. The IP was assisting LVN 1. LVN 1 was observed performing wound care to Resident 22's bilateral hip pressure injuries. LVN 1 was not observed performing hand hygiene during the procedure when she changed gloves and touched a clean and dirty area. On 10/28/21 at 0930 hours, an interview was conducted with LVN 1 and the IP. The IP stated the licensed nurse needed to perform hand hygiene before, during (every time they changed gloves), and after wound care treatment. The IP verified LVN 1 did not perform hand hygiene between changing of gloves during wound care treatment for Resident 26. LVN 1 verified the findings. 4. On 10/28/21 at 0858 hours, a medication administration observation for Resident 30 was conducted with LVN 6. The following was observed: - LVN 6 was observed preparing the oral medications in a medication cup and placing the cup on a tray. LVN 6 was observed elevating the head of the bed and administered the oral medications to Resident 30, then proceeding to the medication cart, and touching the medication cart and the computer. LVN 6 was not observed performing hand hygiene. - LVN 6 prepared and instilled one drop of timolol (medication used to treat increased eye pressure) eye drops in each eye of Resident 30 by gently pulling the lower eye lid. LVN 6 then proceeded to the medication cart and was observed touching the computer. LVN 6 was not observed perforing hand hygiene before and after adminstering the timolol eye drops. - LVN 6 prepared and administered brimonidine (medication used to treat increased eye pressure) eye drop to Resident 30, one drop in each eye by gently pulling the lower eye lid. LVN 6 was not observed performing hand hygiene before administering the brimonidine eye drops. On 10/28/21, at 1013 hours, an interview was conducted with LVN 6. LVN 6 acknowledged she did not perform hand hygiene after the administration of oral medications, before and after the administration of timolol eye drops and before the administration of brimonidine eye drops. LVN 6 stated she was supposed to perform hand hygiene before and after medication administration. On 10/29/21, at 1411 hours, an interview with the DON was conducted. The DON verified the above findings. 5. On 10/28/21 at 0827 hours, a medication administration observation for Resident 77 was conducted with LVN 5. LVN 5 was observed preparing and administering medications to Resident 77. LVN 5 was observed touching Resident 77's hand while administering the oral medications. LVN 5 proceeded to wear gloves without performing hand hygiene. LVN 5 gently pulled down Resident 77's lower eye lid and instilled one drop of artificial tear eye drop in each eye. LVN 5 was not observed performing hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 8 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 hygiene before administering the eye drops. Level of Harm - Minimal harm or potential for actual harm On 10/28/21, at 0846 hours, an interview was conducted with LVN 5. LVN 5 acknowledged he did not perform hand hygiene before administering the eye drops to Resident 77. LVN 5 stated he forgot to perform hand hygiene and acknowledged that he was supposed to perform hand hygiene before administering the eye drops. Residents Affected - Many On 10/29/21, at 1409 hours, an interview with the DON was conducted. The DON stated LVN 5 should have performed hand hygiene before donning gloves to administer the eye drops. Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment and Legionella testing protocols. * The facility failed to ensure the trash bin and laundry hamper were available for used gloves and used washable gowns in Resident 39's room, who was on isolation precautions. * LVN 3 failed to perform hand hygiene while providing wound care to Resident 26. * LVN s 5 and 6 failed to perform hand hygiene during medication administration. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. The facility failed to show documentation a facility risk assessment was conducted to identify, test, and prevent Legionella and other opportunistic waterborne pathogens in the facility. On 10/27/21 at 1041 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the facility did not conduct a facility risk assessment for Legionella. The Maintenance Supervisor verified the facility did not have testing protocols for Legionella. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 9 of 10 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 056151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fullerton, LLC 330 W. Bastanchury Road Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. On 10/26/21 at 1020 hours, Resident 39's room was observed to be on isolation precautions. There was no trash bin for used gloves, and no laundry hamper for used washable gowns available in Resident 39's room. On 10/26/21 at 1024 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified there was no trash bin and laundry hamper near the exit by the door. CNA 2 stated she used the double CNA barrels (linen hampers), one to discard the used gloves, and the other for the used washable gowns. Medical record review for Resident 39 was initiated on 10/26/21. Resident 39 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 10/13/21, for contact and droplet isolation for 14 days related to contact with and suspected exposure to COVID-19 (SARS-CoV-2, a virus which causes severe respiratory infection). On 10/28/21 at 1353 hours, an interview was conducted with the DSD. The DSD verified there were no trash bin for used gloves, and laundry hamper for used washable gowns inside the isolation room. The DSD stated it was the facility's practice to use the CNA barrels to dispose used gloves and used washable gowns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056151 If continuation sheet Page 10 of 10