Health inspection·October 6, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with Certified Nurse Assistant 3 (CNA 3) on 10/04/2023, at 9:50 a.m., CNA 3 stated Resident 76's call light is not working at all upon pushing the call light. The CNA 3 stated, it is very important to make sure all residents' call lights are working properly because call light is their lifeline to bring nurse's attention. During an interview on 10/04/2023, at 9:52 a.m., with License Vocational Nurse 2 (LVN 2), the LVN 2 stated, she did not know Resident 76's call light has not been working and she or other nursing staff should have checked Resident 76's call light when they did rounds. LVN 2 stated she forgot to check it today. During an interview on 10/06/2023, at 11:57 a.m., with Director of Nursing (DON), the DON stated, nurses should check their residents every 2 hour and at that time they should check if their residents' call lights are working properly or within accessible reach. DON stated, call light are important device to assist the resident's need and help residents during emergency situations. During a record review of Resident 76's Care Plan (CP) with initiated date 7/01/2022, the CP indicated Resident 76 has assistance daily living (ADL) self-care performance deficits. The CP intervention indicated, assist ADL's as needed, and attend to resident's needs promptly. B. During a review of Resident 52's admission record, the admission record indicated Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), and muscle atrophy (loss of muscle tissue). During a review of Resident 52's History and Physical (H&P), dated 5/3/2023, the H&P indicated, Resident 1 was able to make simple decisions, but did not have the capacity to make complex medication decisions. During a review of Resident 52's MDS dated [DATE], the MDS indicated Resident 52 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff with bed mobility, dressing, toilet use, personal hygiene, eating, and total dependence (full staff performance required) from two or more persons for transfer. During a concurrent observation and interview on 10/3/2023, at 1:54 p.m., with Resident 52, in Resident 52's room, Resident 52 was sitting on GeriChair between two beds. The call light was placed on left side of bed (Resident 52's bed) close to the left side rail. Resident 52 stated, he was not able to reach his call light because his left side was weak, and the call light was placed too far. Resident 52 stated, he wanted to go back to his bed which was located on his left side, but he could not call his nurse because the call light was unreachable. Resident 52 stated, he felt helpless and disrespected because he could not do anything but wait for his nurse to come in. During an interview on 10/3/2023, at 2:05 p.m., with CNA 1, in Resident 52's room, CNA 1 stated, Resident 52's call light was unreachable because it was placed too far. CNA 1 stated, the call light should have placed on either Geri-chair or on Resident 52's hand. CNA 1 stated, it was important to place the call light within reach, so Resident 52 could get the help he needed. During an interview on 10/4/2023, at 10:23 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, it was nursing staff's responsibility to ensure placing the call light within reach to accommodate the resident's needs and in case of emergency. LVN 1 stated, if the resident could not get the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 2 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0550 help they needed in a timely manner, this could affect their dignity and their self-esteem. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/6/2023, at 10:55 a.m., with Director of Nursing (DON), DON stated, resident's call light should be within reach at all times to meet the resident's needs. DON stated, residents had rights to get the help they needed. DON stated, all staff should respect the residents' dignity and their rights. Residents Affected - Some During a review of Resident 52's CP, dated 5/25/2021, the CP Focus indicated, Resident 52 is at risk for fall related to balance problem. The CP intervention indicated, call lights will be answered promptly and place the call light within reach. During a review of Resident 52's CP, dated 8/26/2021, the CP Focus indicated, Resident 52 had a communication problem related to hearing loss. The CP Intervention indicated, ensure/provide a safe environment: call light within reach. C. During a review of Resident 63's face sheet, the face sheet indicated Resident 63 was admitted to the facility on [DATE] with diagnosis of muscle weakness generalized, hypertension (high blood pressure ), and peripheral vascular disease ( a circulatory condition in which narrowed blood Vessels reduce blood flow to the limbs). During a review of Resident 63's MDS a dated 7/31/2023 indicated Resident 63 has moderate cognitive impairment. The MDS indicated Resident 63 needs limited assistance (Hands on assistance ) with bed mobility( moving in bed ), transfer, and walk in the room. During an observation on 10/3/2023 at 2:22 p.m. CNA 4 enters Resident 63's room and saw Resident 63 sitting at the edge of the bed. Resident 63 stated to the CNA she needs to go to the bathroom . CNA 4 was observed undresses Resident 63 from the waist down without closing the privacy curtain, CNA 4 placed Resident 63 in the shower chair and rolled Resident 63 to the bathroom without a blanket, CNA 4 placed Resident 63 on the toilet and kept the bathroom door open. There was one Roommate present inside the room. During an interview on 10/3/2023 at 2:30 p.m., CNA 4 stated I forgot to pull Resident 4's curtain to provide privacy and when I placed Resident 63 in the bathroom , I did not close the door. CNA 4 stated it is important to always provide the Resident with privacy. During an interview on 10/4/2023 at 10:13 a.m., with the LVN 4 stated Resident 63 should have been covered with a bath blanket when transferring her from the bed to the bathroom . LVN 4 stated the curtain should have been pulled to provide Residents with privacy and the bathroom door closed LVN 4 stated we should always provide privacy this is the Resident's home and it's their rights. During a review of facility's undated, policy and procedure (P/P) titled, Quality of Life-Dignity, the P/P indicated residents shall be treated with dignity and respect at all times. During a review of facility's undated, policy and procedure (P/P) titled, Answering the Call light, the P/P indicated the followings: Be sure that the call light is plugged in at all times. Report all defective call lights to the nurse supervisors promptly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 3 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0550 Answer the resident's call as soon as possible. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Answering the Call Light, undated, indicated, General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within reach of the resident. Residents Affected - Some During a review of the facility's P&P titled, Quality of Life-Dignity, undated, indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation . 2Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 1.Residents should be treated with dignity and respect at all times, 2.Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 3. Staff shall promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and during treatment procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 4 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment made to sure those wishes are carried out should the person be unable to communicate) was discussed and written information was provided to the residents /or responsible parties for one of five sampled residents (Resident 22). This deficient practice violated the resident's right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Finding: During a record review of Resident 22's admission Record (Face Sheet), the Face Sheet indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), dementia (impaired ability to remember, think, or make decisions), hypertension (high blood pressure), and schizoaffective (mental health disorder affect mood, behavior, and thoughts). During a record review of Resident 22's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/30/2023, the MDS indicated Resident 22's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasoning) skills for daily decision making was severely impaired. The MDS indicated Resident 22 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. During a concurrent interview and record review of Resident's 22 medical chart on 10/05/2023, at 1:07 p.m., with Social Services Director 2 (SSD 2), the SSD 2 confirmed there was no advance directive acknowledgement form was completed for Resident 22. The SSD 2 stated, she is not sure if the advance directives was discussed, and written information was provided to Resident 22 and/or responsible party because there is missing signature on the form. The SSD 2 stated the acknowledgement form was important because the form informed the resident and her responsible party regarding the right to formulate an advance directive. During a record review of the facility's policy and procedure (P/P), revised 07/2021 and titled, Advance Directives for Healthcare, the P/P indicated upon admission, all residents and their representatives are presented with written information about their rights to accept or refuse medical or surgical treatment and their right to formulate an advance directive. This information is found in the resident rights portion of the admission packet, Advance Directive Acknowledgement, and upon presentation of a valid Physician Order for Life Sustaining Treatment(POLST). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 5 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 96) was reviewed for changes in Medicare (federal health insurance for people 65 or older) coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. Residents Affected - Few This failure had the potential to result in Resident 96 and/or responsible party not being able to exercise their right to file an appeal. Findings: During a review of Resident 96's admission Record (Face sheet), the admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hypertension (a condition in which the force of the blood against the artery walls is too high), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety (persistent worry and fear about everyday situations). During a record review of Resident 96's Beneficiary Protection Notification Review form (for residents who receive Medicare Part A services) indicated the resident last coverage day for Medicare Part-A Skilled Service was 9/26/2023. During a review of Resident 96's Beneficiary Protection Notification Review Notice of Medicare Non-Coverage (NOMNC) for appeal process, page 2 was not signed. The NOMNC page 2 contained address information on where the resident and/or resident's responsible party can file an appeal of the NOMNC. During an interview with Social Service Designee (SSD 2), on 10/052023, at 9:04 a.m., the SSD 2 stated residents and/or responsible parties should receive NOMNC appeal process information upon discontinuation of services. SDD2 stated she did not mail the notice or give the copy to resident or resident representative. SSD 2 stated the importance of providing the notice in a timely manner was so that the resident and family to were aware of their right to appeal. During a telephone interview with Resident 96's family member (FM 1), FM 1 stated she was not informed by the SSD 2 regarding NOMNC. FM 1 stated she was worried about receiving a bill. During a review of the facility's Policy and Procedure (P&P) titled, Medicare Advance Beneficiary Notice, dated March 2019, the P&P indicated, If the director of admissions or benefits coordinator believes (upon or during the resident's stay) that Medicare (Part A of the Fee for Service Medicate Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). During a review of the facility's P&P titled, Resident Rights, dated December 2016, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about his or her rights and responsibilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 6 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 73) during the use of a pommel cushion (blue cushion placed on a wheelchair) to prevent the resident from sliding. Residents Affected - Some This deficient practice had the potential to result in entrapment and injury. Findings: During a review of Resident 73's Face Sheet (admission record), the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), Type II Diabetes Mellitus (high blood sugar) with diabetic chronic kidney disease (CKD: long term condition where the kidneys do not work as well), anxiety, repeated falls, hypertension (high blood pressure) and cognitive communication deficit. During a review of Resident 73's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/8/2023, the MDS indicated Resident 73's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 73 required extensive assistance for dressing, toilet use, and personal hygiene, transfer from bed, chair, wheelchair, moving between one place to another, dressing, walking, and required supervision for eating. The MDS indicated Resident 73 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 73 used a wheelchair and walker for mobility and have no impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 73 did not have any physical restraints, which are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body. During review of Resident 73's untitled Care Plan (CP) initiated on 6/6/2023, the CP indicated Resident 73 is at risk for fall related to balance problems during transition with contributing factors of history of falling, unsteady gait, and confusion. The CP intervention initiated on 6/7/2023 indicated Resident 73 can have a floormat, have perimeter mattress (a triangular mattress) applied to help resident define the edge of the bed with informed consent (IC- is a principle in medical ethics and medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) obtained by the medical director (MD) and responsible party with risk and benefits explained, and a pommel cushion while on the wheelchair due to Resident 73 having episodes of sliding down with IC obtained by the MD and responsible party. During a review of Resident 73's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and progress note dated 9/29/2023, documented by Minimum Data Set Coordinator (MDSC), the SBAR indicated Resident 73 had an actual fall by the hallway. Resident 73 was sitting upright on the wheelchair by the hallway when a staff that was at the nursing station suddenly heard a bang. The staff observed Resident 73 on the floor and upon assessment noted a bump on the right side of his forehead. Resident 73 was applied ice packs every 15 minutes to the bump. Resident 73 stated he stood up to walk but lost his balance and fell to the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 7 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 73's SBAR Communication Form and progress note dated 6/29/2023, documented by Licensed Vocational Nurse 4 (LVN 4), the SBAR indicated resident was observed on the floor on the left side of the bed. Additional note documented in the progress note on 6/29/2023 by Registered Nurse Supervisor 2 (RNS 2) indicated a Certified Nursing Assistant (CNA) had observed Resident 73 on the floor to the left side of the bed sitting on his buttocks leaning onto his palms trying to go home to his wife. During a review of the Order Summary Report (Physician Order) indicated a perimeter mattress to help resident define the edge of the bed was initiated on 6/29/2023. An order for the pommel cushion while on a wheelchair due to Resident 73 having episode of sliding down was initiated on 10/2/2023. During a review of Resident 73's Fall Risk Evaluation, it indicated the fall intervention placed was to have a pommel cushion while the resident is up in the wheelchair and a perimeter mattress while in bed. During an observation on 10/3/2023 at 10:50a.m. with Resident 73, Resident 73 had pillows on his right side of the back and had wedges on the left side. Resident 73 was observed unable to move. During a concurrent observation and interview on 10/3/2023 at 1:01p.m. with Quality Assurance Nurse (QA), QA showed me a blue cushion in which Resident 73 was sitting on while in the patio. QA stated this cushion was the pommel cushion and attempted to show that the cushion was in place and cannot be moved by pulling on the cushion. During a concurrent observation, interview, and record review on 10/6/2023 at 2:02p.m. with Registered Nursing Supervisor 1 (RNS 1), RNS 1 stated a restraint can be described as putting a belt on the arms, mittens for residents who try to pull out their gastrostomy tube (G-tube: surgically placed device to provide nutrients in the stomach) or if a resident is sitting and placing an object so they cannot move. RNS 1 stated Resident 73 had an order for a perimeter mattress on 6/29/2023. RNS 1 stated a perimeter mattress is kind of like a restraint but is also used to define the edge of the bed and would require a consent prior to applying the mattress. RNS 1 stated when the resident is on a wheelchair, a pommel cushion is used to prevent them from sliding in the wheelchair that was ordered on 10/2/2023. RNS 1 stated when the resident goes to activities, the pommel cushion is placed in the wheelchair. RNS 1 initially stated a consent is not required for the pommel cushion since it is only to prevent the resident from sliding, but later stated a consent is needed for a pommel cushion as it can be considered a restraint. RNS 1 stated any object or device that can be used as a restraint would require an order and the consent of the doctor and family member prior to the mattress or cushion being placed. RNS 1 stated since Resident 73's admission on [DATE], there is no indication that Resident 73 had the perimeter mattress or the pommel cushion until the perimeter mattress was ordered on 6/29/2023. RNS 1 stated whatever service that was provided or ordered for the resident is supposed to be documented in the progress note or as a weekly summary in the progress note since it is a form of communication between the staffs. RNS 1 stated Resident 73 had anxiety and dementia and cannot say that Resident 73's fall would have been prevented but stated the interventions (perimeter mattress and pommel cushion) for Resident 73 is a restraint and the doctor may not want the perimeter mattress. RNS 1 stated the perimeter mattress is placed on both sides of the bed, but even with the perimeter mattress, the resident would need frequent visual checks as they can still fall out of bed as it is only to help define the end of the bed. It was noted the perimeter mattress is not fully attached to the bed and was loose, indicating the resident can still fall out of the bed. During a concurrent interview and record review of Resident 73's physician's order and consent form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 8 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 10/6/2023 at 6:17p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated residents are assessed quarterly and indicated there are different types of restraints such as physical and chemical restraint. MDSC stated a restraint is used to limit the movement of an individual, but it would not be considered a restraint if they are able to move freely. MDSC stated if a restraint is required, they would get an order from the doctor, get an IC, do an assessment, do a CP, and have an Interdisciplinary Team (IDT: a meeting with various department heads to discuss resident's plan of care) meeting. MDSC stated if a resident is able to stand up, but a table is placed in front of them and they cannot push the table, it would depend on the nurse's assessment on whether or not it would be considered a restraint. MDSC stated they do not use restraints at the facility and if a resident is a high risk for fall, they use a pommel cushion to prevent the resident from sliding out of the chair. MDSC stated if a resident had a pommel cushion and is unable to remove it, the resident would need to be assessed if they are able to take it out. MDSC stated a pommel cushion does not need an IC as it is not a restraint. MDSC stated in the MDS Section P: Restraints and Alarms indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body MDSC stated this is the only assessment at this time for safety on the fall risk for Resident 73's recent fall on 9/29/2023 MDSC stated there were no consent forms in Resident 73's chart for both the pommel cushion and the perimeter mattress. MDSC stated on the order, it indicated the doctor got an IC from the family, but there are no consent forms in the chart. MDSC stated an IC is important and is needed to notify the family for new interventions so that the family won't be surprised if they came to visit the resident. During a review of the facility's P&P titled Resident Assessments revised on November 2019, the P&P indicated a significant change in status assessment (SCSA: comprehensive assessment of the resident) is required when a resident begins to use a restraint of any type when it was not used before. During a review of the facility's P&P titled Use of Restraints revised on April 2017, the P&P indicated restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: how the restraint will be used to benefit the resident's medical symptoms and the type of restraint, and period of time for the use of the restraint. Documentation regarding the use of restraints shall include the length of effectiveness of the restraint time and observation, range of motion and repositioning flow sheets. . During a review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring revised on March 2019, the P&P indicated if any devices (restraints) are prescribed, the IDT will monitor the situation to ensure that they are beneficial to the individual (for example, enhancing function and improving symptoms) and are not causing complications or disabling the individual. Over time, the staff will reduce the use or remove such devices or will document why such attempts are not feasible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 9 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 57) was reviewed for Preadmission Screening and Resident Review (PASARR) in a timely manner. This failure had the potential to result in the resident not receiving appropriate care or delay in treatment. Findings: During a review of Resident 57's admission Record (Face sheet) indicated Resident 57 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a mental health disorder including schizophrenia and mood disorder symptoms) encephalopathy (brain disease that alters brain function or structure) unspecified dementia (dementia without a specific diagnosis), and anxiety (persistent worry and fear about everyday situations). During a review of Resident 57 Minimum Data Set (MDS, a standardized comprehensive assessment and care-screening tool, dated 7/20/2023, indicated Resident 57 has schizoaffective disorder, encephalopathy, unspecified dementia, and anxiety. During a review of Resident 57's Preadmission Screening and Resident Review (PASARR) Level 1 Screening dated 9/03/ 2019, indicated resident 57 Level I PASARR was negative and the form was incompletely filled out. During interview with MDS Coordinator (MDSC), on 10/04/2023, the MDSC stated PASARR should be done upon admission, when new psychiatric medication was added to care plan, and when resident has a change of condition (COC). The MDSC indicated Resident 57's PASARR was incomplete on 9/3/2019. Resident 57 had a new diagnosis of schizoaffective disorder on 09/2021, but the PASARR was not reevaluated. During an interview with the Director of Nursing (DON) on 10/06/2023, at 10:55 a.m., the DON stated the MDSC was in charge of PASARR and should be done upon admission and if there any change of condition. The DON stated if the PASARR was not done correctly or not done in a timely manner, there would be a delay in treatment. During a review of the facility's Policy and Procedure (P&P) titled, Resident Behavior and Facility PracticesResident Behavior dated 3/2019, indicated New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 10 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness) ) screening was completed for two of five sampled residents (Resident 14 and Resident 22) who were diagnosed with mental disorder (MD). Residents Affected - Some This deficient practice had the potential for Resident 14 and 22, not receiving appropriate behavioral services Findings: During a record review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including anxiety (feeling of fear, and uneasiness) disorder, bipolar disorder (mental illness that cause unusual shifts in a person's mood, energy, activity levels, and concentration), and major depressive disorder (loss of pleasure or interest in activities). During a record review of Resident 14's History and Physical (H/P), dated 8/28/2023, the H/P indicated Resident 14 does not have the capacity to understand and make decisions. During a record review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/09/2023, the MDS indicated Resident 14's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasoning) skills for daily decision making was severely impaired. The MDS indicated Resident 14 required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. During a concurrent interview and record review on 10/06/2023, at 1:54 p.m., with MDS Coordinator (MDSC), MDSC confirmed that Resident 14's PASSAR Level I screening, was not done correctly due to missing the assessment on Section V-Mental Illness because Resident 14 was admitted to the facility with MD. The MDSC stated, MDSC was responsible for following up with PASSAR Level I screening was done correctly upon admission and quarterly. During a record review of Resident 22's Face Sheet, the Face Sheet indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing daily activities), anxiety disorder, and schizoaffective disorder (mental illness that can affect your mood and behavior). During a record review of Resident 22's History and Physical (H/P), dated 5/30/2023, the H/P indicated Resident 22 does not have the capacity to make decisions. During a record review of Resident 22's MDS, dated [DATE], the MDS indicated Resident 22's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 22 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. During a concurrent interview and record review on 10/06/2023, at 1:43 p.m., with MDSC, MDSC confirmed that PASSAR Level I was not done for Resident 22 upon admission, or prior to the admission. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 11 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MDSC stated, previous MDSC should have conduct Resident 22's PASSAR assessment if they did not receive one prior to the admission and follow up on it within 48 hours. The MDSC stated, if PASSAR screen was not done or was not completed correctly, we cannot treat residents necessary care for those residents. During an interview on 10/06/2023, at 12:19 p.m., with Director of Nursing (DON), the DON stated the MDSC should be responsible person to check PASARR Level I was completed correctly. The DON stated, it was important to complete the level I because it gives us specific guidelines regarding specialized care to residents with MD. During a record review of the undated, facility's policy and procedure (P/P) titled, Behavioral Assessment, Intervention, and Monitoring, the P/P indicated the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. The P/P indicated all residents will receive a Level I PASARR screen prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 12 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a care plan for one of three sampled residents (Resident 13) who has decreased hearing. This deficient practice had the potential to negatively affect the delivery of necessary care and services. Findings: During a review of Resident 13's admission record (face sheet), the face sheet indicated resident 13 was initially admitted to the facility on [DATE] with a diagnosis of diabetes mellitus with other specified complications (high blood sugar ) , hypertension ( high blood pressure), bilateral osteoarthritis of the knee ( when the cartilage that lines your joints is worn down ). During a review of Resident 13's history and physical (H&P) report dated 6/3/2015, the H&P indicated Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set ( MDS -a standardized assessment and care planning tool) dated 1/1/2023, the MDS indicated Resident 13 requires limited assistance ( physical help in guided maneuvering of limbs or other non- weight bearing assistance ) with transfers, Dressing and toilet use. During a review of Resident 13's Order Summary Report (OSR), the OSR indicated an order was placed on 6/14/2023 for Resident 13 to have an ENT (Ears , nose, and throat) consult with follow up treatment as indicated. During a review of Resident 13's ENT physical exam appointment on 6/15/2023 , the physical exam indicated Resident 13 had moderate hearing loss bilaterally. During an observation at the resident council meeting (is an organized group of residents who meet regularly to discuss and address concerns about their rights) on 10/4/2023 at 2:00 p.m., Resident 13 stated to the audience I cannot hear what everyone is saying. During an Interview on 10/5/2023 at 1:08 p.m., with Licensed Vocational Nurse 6 (LVN), LVN 6 stated when speaking to Resident 13 we need to get close to her or stand where she can see and hear when we are speaking to her. LVN stated there was no care plan and should have been a care plan to address Resident 13's decreased hearing. LVN 6 stated a care plan help to assure that a resident's need are being met. During an interview on 10/4/2023 at 10:09 a.m., with Social Service Designee (SSD), SSD stated I am aware of Resident 1,s hearing deficit and there is no care plan addressing this. SSD stated the reason we do care plans is to make sure a resident's needs are being met. During an interview on 10/5/2023 at 1:18 p.m., with Director of Nursing (DON), the DON stated if there is a problem with a Residents hearing we need start a care plan this outline what needs to be done to manage the residents needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 13 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm During a review of the policy and procedure (P&P) titled , Comprehensive Assessment and the Care Delivery Process, revised 11/2019 indicates, comprehensive assessments will be conducted to assist in developing person-centered care plans. Information analysis steps include. b. define conditions and problems that are causing, or could cause, or could cause problems. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 14 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update and implement the comprehensive care plan for one of one sampled resident (Residents 73) who sustained a fall from his wheelchair. This failure resulted in Resident 73 sustaining an injury from the actual fall. Findings: During a review of Resident 73's Face Sheet (admission record), the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), Type II Diabetes Mellitus (high blood sugar) with diabetic chronic kidney disease (CKD: long term condition where the kidneys do not work as well), anxiety, repeated falls and hypertension (high blood pressure) . During a review of Resident 73's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/8/2023, the MDS indicated Resident 73's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 73 required extensive assistance for dressing, toilet use, and personal hygiene, transfer from bed, chair, wheelchair, moving between one place to another, dressing, walking, and required supervision for eating. The MDS indicated Resident 73 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 73 used a wheelchair and walker for mobility and have no impairments on both the upper and lower extremities (arms and legs). During review of Resident 73's untitled Care Plan (CP) initiated on 6/6/2023, the CP indicated Resident 73 is at risk for fall related to balance problems during transition with contributing factors of history of falling, unsteady gait, and confusion. The CP goal indicated to decrease significant injury as a result from falls in the next three months. The CP intervention initiated on 6/7/2023 indicated Resident 73 can have a floormat, have perimeter mattress (a long triangular padding) applied to help resident define the edge of the bed with informed consent (IC) obtained by the medical director (MD) and responsible party with risk and benefits explained, and a pommel cushion while on the wheelchair due to Resident 73 having episodes of sliding down with IC obtained by the MD and responsible party. During a review of Resident 73's untitled CP initiated on 6/30/2023 indicated Resident 73 had an actual fall with no injury. Additionally, it indicated Resident 73 had a fall on 9/29/2023 and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) on the right side of his forehead. The CP intervention initiated on 6/30/2023 indicated to do neurological checks every shift for any unusual loss of consciousness, monitor for pain, transfer to acute hospital, and may use a pommel cushion while on the wheelchair due to Resident 73 having episodes of sliding down with IC obtained by the MD and responsible party. During a review of the Order Summary Report (Physician Order) indicated a perimeter mattress to help resident define the edge of the bed was initiated on 6/29/2023. An order for the pommel cushion while on a wheelchair due to Resident 73 having episode of sliding down was initiated on 10/2/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 15 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 73's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and progress note dated 9/29/2023, documented by Minimum Data Set Coordinator (MDSC), the SBAR indicated Resident 73 had an actual fall by the hallway. Resident 73 was sitting up right on the wheelchair by the hallway when a staff that was at the nursing station suddenly heard a bang. The staff observed Resident 73 on the floor and upon assessment noted a bump on the right side of his forehead. Resident 73 was applied ice packs every 15 minutes to the bump. Resident 73 stated he stood up to walk but lost his balance and fell to the floor. During a review of Resident 73's SBAR Communication Form and progress note dated 6/29/2023, documented by Licensed Vocational Nurse 4 (LVN 4), the SBAR indicated resident was observed on the floor on the left side of the bed. Additional note documented in the progress note on 6/29/2023 by Registered Nurse Supervisor 2 (RNS 2) indicated a Certified Nursing Assistant (CNA) had observed Resident 73 on the floor to the left side of the bed sitting on his buttocks leaning onto his palms trying to go home to his wife. During a review of Resident 73's Computerized Tomography (CT: a series of X-ray images taken from different angles of the body) of the head without contrast (a substance used to enhance to visibility of certain structures) Radiology Report completed on 9/30/2023 indicated there was a large right soft tissue hematoma. During a concurrent interview and record review on 10/5/2023 at 11:31a.m. with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated when a resident is a fall risk, some of the prevention method include moving residents close to the nursing station, have perimeter mattress, floor mat (for residents who had falls), and bed alarms. LVN 6 stated if a resident fell, they will do an assessment, do a change of condition (COC), take vital signs, notify family and doctor, monitor the resident for 72 hours, do a fall risk assessment, and assess for pain. LVN 6 stated Resident 73 fell on 9/29/2023 at night by the hallway in his wheelchair with a bump on his forehead. LVN 6 stated Resident 73 stood up and tried to walk but lost his balance and fell to the floor. LVN 6 stated there is a CP for a previous fall that occurred on 6/30/2023 with no injury and underneath the initial fall, the CP was updated with Resident 73's recent fall on 9/29/2023 which resulted in a hematoma on his right forehead with an injury. LVN 6 stated there should have been a separate CP created for the actual fall on 9/30/2023 instead of adding this information onto a previous fall CP. LVN 6 stated every COC has to have a CP the same day to know when the resident actually fell and add new interventions to prevent another incident from occurring. During a concurrent interview and record review on 10/05/2023 at 4:29p.m. with MDSC, MDSC stated Resident 73 recently had a fall on 9/29/2023 and had a CP for at risk for fall and one for an actual fall with no injury when Resident 73 sustained an injury. MDSC stated the CP should have been updated the same day and if it revised, it should reflect Resident 73's current fall. MDSC stated a CP is initiated at admission and is revised quarterly, annually, or when there are any significant changes. MDSC stated it is important to follow up on the CP to see if the interventions are effective as the resident might not get the proper treatment or care if the CP is not updated. During a concurrent interview and record review on 10/6/2023 at 2:06p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated an order for the perimeter mattress was placed on 6/29/2023 and Resident 73 was initially admitted on [DATE]. RNS 1 stated Resident 73 had a risk for fall CP that was done on 6/6/2023 since he had a history of falls. RNS 1 stated interventions are a plan and indicated the facility may apply the perimeter mattress and pommel cushion for Resident 73. RNS 1 stated nursing CPs have to be followed and the use of perimeter mattress and pommel cushion needs a consent from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 16 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the family member and the doctor prior to being initiated. RNS 1 stated since Resident 73's admission, it does not indicate Resident 73 had the perimeter mattress or cushion based on the nursing progress notes and the perimeter mattress was ordered on 6/29/2023. RNS 1 stated all of the interventions in the CP have to be done as much as possible to prevent the resident from repeated falls. During a review of the facility's P&P titled, Care Plans--Comprehensive revised on September 2010, the P&P indicated assessments of residents are ongoing and are plans are revised as information about the residents and the residents' condition change. During a review of the facility's P&P titled Safety and Supervision of Residents revised on July 2017, the P&P indicated implementing interventions to reduce accident risks and hazards shall include the following: ensuring that interventions are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 17 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 14, and Resident 57) were provided with a communication board and language translating service were readily available. Residents Affected - Some These deficient practices lead the potential Resident 14 and 57 not communicating her needs effectively with staff and delay in care and services being rendered for Resident 14 and 57. Findings: a. During a record review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and apraxia (loss of ability to carry out skilled movement and gestures). During a record review of Resident 14's History and Physical (H/P), dated 8/28/2023, the H/P indicated Resident 14 does not have the capacity to understand and make decisions. During a record review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/09/2023, the MDS indicated Resident 14's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasonings) skills for daily decision making was severely impaired. The MDS indicated Resident 14 required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. During a concurrent observation and interview on 10/04/2023, at 9:37 a.m., with Certified Nurse Assistant 4 (CNA 4), Resident 14 continued saying [NAME], [NAME] and CNA 4 stated, he is not sure what she is saying. CNA 4 stated, Resident 14 cannot say any other words, except [NAME], and he usually assumed what Resident 14 asked. CNA 4 stated, he does not use communication board when he talked to the resident. CNA 4 stated, he did not know where he can find the communication board and it is not readily available in Resident 14's room. During an interview on 10/06/2023, at 12:11 p.m., with Director of Nurse (DON), the DON stated, residents with aphasia, nurse should communicate with those residents by using communication boards for their needs and it should be located in the resident's room. During a record review of Resident 14's Care Plan (CP), the CP indicated Resident 14 has communication problem difficulty communicating words or finishing thoughts unclear speech. The CP intervention indicated assist resident in decision making by giving simple choices. During a review of facility's undated, policy and procedure (P/P), tilted Residents who present with Communication Barriers, the P/P indicated, communication boards will be provided at no charge to the resident so that non-English speakers, or aphasic residents can use pictograms to communicate needs and desires. B. During a record review of Resident 57's Face Sheet, the admission record indicated Resident 57 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 18 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0676 Level of Harm - Minimal harm or potential for actual harm was admitted to the facility on [DATE] with diagnoses including cerebral infarction on left side of brain (blood supply to the left side of the brain is stopped. The left side of the brain controls the right side of the body. It also controls the ability to speak and use language.), dementia (a loss of thinking ability, memory, attention, logical reasoning, and other mental abilities), hemiplegia of right side (right sided muscle paralysis or weakness), and hemiparesis of right side (weakness or the inability to move on right side of the body). Residents Affected - Some During a review of Resident 57's H&P, dated 10/5/2023, the H&P indicated, Resident 57 had no capacity to understand and make decisions. During a record review of Resident 57's MDS, dated [DATE], the MDS indicated, Resident 57 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff for bed mobility, dressing, personal hygiene, total dependence (full staff performance every time) from two or more staff for transfer, toilet use, and supervision and set up help for eating. During an observation on 10/3/2023, at 2:12 p.m., in Resident 57's room, Resident 57 started yelling in her primary language (native language or mother tongue) and there was no communication board in her room. During a concurrent observation and interview on 10/3/2023, at 2:22 p.m., with CNA 2, in Resident 57's room, Resident 57 was still yelling in her primary language. CNA 2 stated, Resident 57 was able to speak limited Spanish, but she did not understand what the resident was saying. CNA 2 stated, she did not know Resident 57's primary language, so she could not find out why the resident was yelling. CNA 2 stated, she could not find the communication board in Resident 57's room and did not know if there was any language translating service line available at the facility. CNA 2 stated, there should be a way to communicate with the Resident 57, because Resident 57 might need help for emergency and feel isolated. During an interview on 10/4/2023, at 10:23 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 57 was able to communicate with limited Spanish, but the resident could not understand medical procedure or complex content. LVN 1 stated, it was important to provide information in Resident 57's primary language and to accommodate the resident's needs by communicating with the resident. LVN 1 stated, there was no language translating service number available at the facility. During an interview on 10/6/2023, at 10:55 a.m., with DON, the DON stated the facility utilized staff who was able to speak different language other than English to communicate with the residents who were unable to speak English. DON stated, Resident 57 was speaking Cantonese, but there was no staff that could speak Cantonese. DON stated, it was important to provide communication board that way of communication for the residents to accommodate their needs and to provide proper treatment. During a review of Resident 57's CP, dated 7/19/2021, the CP Focus indicated, Resident 57 had potential language barrier. Resident 57 was able to speak Cantonese and some Spanish. The CP Interventions indicated, use communication board, and use interpreters as possible. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated, Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .e. Communication (speech, language, and any functional communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 19 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0676 systems). Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Residents Who Present with Communication Barriers, undated, the P&P indicated, Policy: It Is the policy of this facility to meet the needs of residents who present with communication barriers. RATIONALE: Communication supports psychosocial well-being by enabling residents to participate in their care. Procedure . Communication boards will be provided at no charge to the resident so that non-English speakers, or aphasic residents can use pictograms to communicate needs and desires. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Translation and /or Interpretation of Facility Services, revised 11/2020, the P&P indicated, Policy Interpretation and Implementation . 12. Interpreters and translators must be appropriately trained in medical terminology, confidentiality of protected health information, and ethical issues that may arise in communicating health-related information. 13. Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 20 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician's order for foot care for one of one sample resident (Resident 97). Residents Affected - Few This deficient practice had the potential for placing the resident at risk for complications such as infection or bleeding of the feet. Finding: During a review of Resident 97's Face Sheet (admission record), the Face Sheet indicated Resident 97 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (paralysis and partial weakness on one side of the body) following a cerebral infarction (impaired blood flow to the brain) affecting the left non-dominant side, atrial fibrillation (irregular heart rhythm), cerebral aneurysm (bulging of the vessel that supplied to the brain) nonruptered, muscle weakness, contracture on the left hand, abnormalities of gait and mobility, Type II Diabetes Mellitus (high blood sugar without complications), and anxiety. During a review of Resident 97's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 8/21/2023, the MDS indicated Resident 97's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 97 required extensive assistance for dressing, toilet use, and personal hygiene and is totally dependent, transfer from bed, chair, wheelchair and move between one place to another. The MDS indicated Resident 97 was not steady transferring from sit to standing position and surface to surface transfers and is able to stabilize with staff assistance. The MDS indicated Resident 97 used a wheelchair for mobility and have an impairment on the upper extremities (arm, hand, shoulder). During review of Resident 97's untitled CP initiated on 5/16/2023, the CP indicated Resident 97 had potential for bleeding, bruise, skin treat secondary to aspirin, Plavix, and apixaban. During a concurrent interview and record review on 10/6/2023 at 1:44p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 97 does not have any podiatry consultation and social service is usually the one that makes the appointments for these services. RNS 1 stated Resident 97 had gotten her toenails cut once since she had been here in May 2023. During a concurrent observation and interview on 10/6/2023 at 1:54p.m. with RNS 1, RNS 1 stated Resident 97's toenails are long on the right foot, but it is still okay as it is not digging in to her skin. Resident 97 stated it is not okay when she goes to physical therapy (PT) and her toenails are going in to skin. RNS 1 observed Resident 97's left big toe and stated that it was long. Resident 97 stated that she had asked three times to get her toenails cut but no one had attended to her request. RNS 1 stated if a Certified Nursing Assistant (CNA) observed that a resident's finger nail was long, or if they have a small cut, or if the resident wants a haircut, a CNA should notify the nurses. RNS 1 stated Resident 97 does not have an order for podiatry at this time and should have had one as it is the facilities protocol to put in a podiatry request for residents who are diabetic. RNS 1 stated if toenails are not cut on a timely manner, the toenails will become hard and would be difficult to cut, which may lead to bleeding and cause complications as diabetic residents are more prone to cuts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 21 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's P&P titled, Quality of Life-Dignity revised on August 2009, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). During a review of the facility's P&P titled, Ancillary Services revised on May 2019, the P&P indicated it is the policy of this facility to obtain dental, optometry, ophthalmology, podiatry, audiology (ENT: Ears Nose Throat) and psychological/psychiatric services for residents who present with or request a need for these ancillary services. Event ID: Facility ID: 056164 If continuation sheet Page 22 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, the resident, who was assessed as being a moderate risk for falls, did not fall for one of one sampled resident (Resident 89). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence brief changed and left the resident's room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility's policy and procedure (P&P) titled Answering the Call Light to summon other staff help by using the call light for assistance to get incontinence care items when CNA 6 was in the Resident 89's room. 3. Ensure Resident 89's room was changed closer to the nursing station for a closer observation/visibility as care planned. These deficient practices resulted in Resident 89 attempting to remove his soiled incontinence brief (diaper) himself and fall out of bed sustaining a left hip fracture and subsequent transfer to a General Acute Care Hospital (GACH) for evaluation and treatment on 8/8/2023. At the GACH Resident 89 was diagnosed with closed left basicervical (area located at the junction between the femoral [the bone of the thigh] neck [part of the bone that connects the head of the bone with the middle part of the bone] and intertrochanteric region [area where the femur changes from a vertical bone to a bone angling at a 45° angle]) femur fracture requiring left hip open reduction internal fixation ([ORIF]-a type of surgery used to hold the broken bone together) with cephalomedullary nail (a surgical devise to stabilize the fracture). Resident 89 returned to the facility on 8/11/2023 with 11 staples on the incision (surgical cut) measured 5.0 centimeters [(cm) a unit of measure] by 0.1 cm to superior (top) surgical site of left hip, seven staples on the incision measured 4.0 cm by 0.1cm to inferior (bottom) surgical site of a left hip. Findings: During a review of Resident 's 89 admission Record (Face Sheet), the Face Sheet indicated Resident 89 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty in walking, unspecified dementia (impaired ability to remember, think, or make decisions), spinal stenosis (space inside the backbone is too small) of lumbar region (lower part of the back) type 2 diabetes (a disease that occurs when a person's blood glucose, also called blood sugar, is too high) and transient ischemic attack [(TIA) a condition when blood supply to part of the brain was briefly interrupted). During a review of Resident 89's History and Physical (H/P), dated 8/12/2023, the H/P indicated, Resident 89 had the capacity to understand and make decisions. During a review of Resident 89's Minimum Data Set [(MDS), a standardized assessment and care-screening tool], dated 6/07/2023, the MDS indicated Resident 89's cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making were mildly impaired. The MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 23 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 - Actual harm Residents Affected - Few indicated, Resident 89 required extensive physical assistance from staff for bed mobility, transfer, walk in room, toilet use, and personal hygiene. The MDS indicated Resident 89 was frequently (seven or more episodes) incontinent with urinary continence and frequently (two or more episodes) incontinent of bowel. During a record review of Resident 89's Fall Risk Evaluation dated 6/07/2023 and timed at 5:00 p.m., the Fall Risk Evaluation indicated Resident 89 was scored seven (0-5 low risk, 6-20 medium risk, 21-45 high risk) which indicated moderate risk for falls. The Fall Risk Evaluation indicated to provide Resident 89 with safe environment, clutter free, necessary belonging within reach, and attend needs in a timely manner. During a review of Resident 89's GACH Emergency Department (ED) notes, dated 8/08/2023, and timed at 10:51 a.m., the ED notes indicated Resident 89 presented to the ED after rolling out of bed and landing on his left hip. The ED notes indicated Resident 89 was diagnosed with a nondisplaced intertrochanteric left hip fracture. The ED notes indicated Resident 89 undergo ORIF of the left hip. During a review of Resident 89's GACH Computerized tomography [(CT) computerized x-ray {a photographic or digital image of the internal composition of something}] scan dated 8/08/2023, CT scan indicated the resident had an acute nondisplaced intertrochanteric fracture of the proximal left femur neck fracture. During a review of the facility's Licensed Nurses Progress Note (LNPN), dated 8/07/2023, and timed at 9:56 p.m., the LNPN indicated Resident 89 was found lying on the floor in the resident's room. The LNPN indicated Resident 89 was complaining of pain of the left hip and the resident had a purple discoloration on the forehead. The LNPN indicated 911 (emergency number) was called and Resident 89 was transferred to GACH. During a review of Situation Background Assessment and Recommendation [(SBAR) communication framework that can help teams share information about the conditions of the resident] form and LNPN dated 8/07/2023, and timed at 9:51 p.m., the SBAR indicated, at around 8:30 p.m., clinical nurse (CN) summoned the registered nurse supervisor (RNS) to Resident 89's room. The CN observed Resident 89 lying on the floor. SBAR indicated Resident 89 complained of pain level five out of 10 on a zero to ten pain rating scale (0 is no pain and 10 is worse possible pain) of the left hip. SBAR indicated Resident 89 was transferred to the GACH for further evaluation at 8:45 p.m. During a review of Resident 89's Care Plan (CP) titled, Risk for fall related to balance problem during transition (sit to stand) initiated on 6/1/2023, the CP indicated the resident required assistance with walking and bed mobility. The CP indicated the goal for Resident 89 was to decrease significant injury as a result from falls and to minimize the risk for potential for fall related to resident's getting out of bed without waiting for staff assistance. The CP interventions included to provide Resident 89 with the adequate support from staff during activities of daily living (ADL) and transfers. The CP also indicated to move Resident 89 to a room close to the nursing station for a better visibility. During an interview on 10/05/2023 at 11:42 a.m. with Resident 89, the resident stated he called for assistance by using the call light and waited for a long time and no one came to help. Resident 89 stated he needed his soiled diaper changed. Resident 89 stated it felt like he was waiting for more than an hour. Resident 89 stated he just kept on pressing the call light and no one was responding to his call for help. Resident 89 stated, when CNA 6 came in response to his (Resident 89's) call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 24 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 - Actual harm Residents Affected - Few light, CNA 6 saw his soiled diaper needed to be changed. Resident 89 stated CNA 6 did not change his diaper and told him (Resident 89) to wait until he (CNA 6) comes back and left the room. Resident 89 stated, he had been waiting for a long time, so he decided to remove his diaper by himself. Resident 89 stated, when he attempted to sit up in bed, he felt dizzy and rolled out of his bed to the floor. Resident 89 stated, he had severe pain to his left side and screamed in pain. During a phone interview on 10/05/2023, at 3:01 p.m., with CNA 6, CNA 6 stated on 8/07/2023 around 8:20 p.m., he answered Resident 89's call light and found Resident 89 trying to remove his diaper while in bed. CNA 6 stated to Resident 89 to leave the diaper on and left the room. CNA 6 stated he explained to Resident 89 that he would grab some towels and water to clean him. When CNA 6 came back, Resident 89 was on the floor adjacent to his bed laying on his back complaining of left-side pain. During an interview on 10/5/2023 at 3:24 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 89 can make his needs known to staff. LVN 3 stated Resident 89 was assessed as moderate risk for fall and should not be left alone and provided the care needed. LVN 3 stated the Director of Rehabilitation (DOR) assess the residents upon admission and staff should provide the residents with assistance based on the DOR assessment. During a concurrent interview and record review on 10/06/2023, at 8:41 a.m., with the DOR, the DOR reviewed Physical Therapy (PT) Discharge Summary, and stated, Resident 89 was able to safely ambulate using front-wheeled walker (assistive device) with supervision or touching assistance for proper sequencing (correct way of walking with assistive device) Physical Therapy Discharge summary dated from 6/20/2023 to 8/7/2023 indicated, Resident 89 required supervision or touching assistance with bed mobility, transfer, and ambulation. The DOR stated, there was a great possibility that Resident 89 could fall if Resident 89 gets out of bed by himself and/or walks by himself. The DOR stated, he did not recommend at all for Resident 89 to walk or get out of bed by himself. During a review of Resident 89's PT Discharge summary dated from 6/20/2023 to 8/7/2023, the PT Discharge Summary indicated, Resident 89 required supervision or touching assistance with bed mobility (roll left and right), transfer from bed to chair, ambulation, and picking up object. During a phone interview on 10/6/2023 at 8:54 a.m. with LVN 4, LVN 4 stated he remembered that on 8/7/2023 during 3 p.m. to11 p.m. shift at around 8 p.m. he heard a loud scream coming from Resident's 89's room when he (LVN 4) was attending to another resident. LVN 4 stated he walked to Resident 89's room and saw Resident 89 was lying on the floor, on his left side. LVN 4 stated, he remembers that Resident 89 needed moderate to maximum physical assistance from one staff. Resident 89's room was located about 40 feet away from the nursing station. LVN 4 stated, CNA 6 told him that CNA 6 walked out of Resident 89's room to get water and towel and when CNA 6 came back to Resident 89's room, Resident 89 was found on the floor. LVN 4 stated, Resident 89 was not supposed to be left alone when the resident needed help because Resident 89 has been trying to stand up by himself and tried to be independent. During an interview on 10/06/2023, at 12:11 p.m., with the Director of Nursing (DON), the DON stated, if a resident was at moderate risks for falls, she educated a resident to use a call light for assistance. The DON stated after Resident 89's fall on 8/8/2023 we moved the resident in a room closer to the nursing station. The DON stated the facility staff should answer a call light promptly especially when a resident is at the risk for fall. The DON sated the facility staff discuss and communicate with each other to identify the residents who were at a moderate to high risk for fall. The DON stated the facility staff should not left Resident 89 alone since CNA 6 noticed Resident 89 felt (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 25 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 - Actual harm uncomfortable with having on a soiled diaper. The DON stated if staff noticed that the resident would try to clean himself or herself up, staff should stay with the resident and ask other staff (CNA/LVN) to get the needed supply. The DON stated CNA 6 should have used the call light to ask for staff assistance and not leave resident 89's room. Residents Affected - Few During a review of the facility's undated P&P titled, Fall Prevention Program, revised 12/2007, the P&P indicated to assist resident with toileting needs upon rising before and after meals, before and after bed and as needed. During a review of the facility's P&P titled, Safety and Supervision of Residents revised 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's undated P&P titled, Answering the Call Light. (undated) the P&P indicated staff to answer the resident's call as soon as possible. The P&P indicated, if assistance is needed when staff enter the room, summon help by using the call signal. During a review of the facility's P&P, titled Care Plans-Comprehensive, revised 09/2010, the P&P indicated, the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representatives (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 26 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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, and record review, the facility failed to accurately account for the use of one dose of a controlled substance (medications with a high potential for abuse) affecting Resident 17 in one of two inspected medication carts (West Station Cart 2). This deficient practice increased the risk that Resident 17 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of [NAME] Station Cart 2, on 10/4/23 at 1:37 PM, with the Licensed Vocation Nurse (LVN 2), the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 17's Narcotic and Hypnotic Record for clonazepam (a medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) indicated there was one dose left, however, the medication card was missing from the medication cart. LVN 2 stated she administered the missing dose of clonazepam for Resident 17 around 9:00 AM today. LVN 2 stated she failed to sign the Narcotic and Hypnotic Record at that time because she was distracted by other tasks. LVN 2 stated it is important to sign the Narcotic and Hypnotic Record immediately after a controlled medication is administered to a resident to ensure accountability of the controlled substances, prevent diversion (transfer of a medication for any use other than what the prescriber intended), and ensure that the resident does not receive it more often than intended. LVN 2 stated if a resident receives a controlled medication like clonazepam more often than prescribed, it could cause medical complications. A review of the facility's policy Controlled Substances, revised April 2019, indicated Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . Upon administration, the nurse administering the medication is responsible for recording . time of administration, quantity of medication remaining, and signature of the nurse administering the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 27 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to enter or clarify a prescriber's order to reduce the dose of Seroquel (a medication used to treat mental illness) between 9/20/23 and 10/5/23 for one of five sampled residents (Resident 52.) Residents Affected - Few As a result of this deficient practice, Resident 52 received a higher than necessary dose of Seroquel between 9/20/23 and 10/5/23 which increased the risk that he could have experienced adverse effects (unwanted side effects of medication therapy like drowsiness or constipation) related to the use of Seroquel leading to a decline in his quality of life. Findings: A review of Resident 52's admission Record (a document containing a resident's demographic and diagnostic information), dated 10/5/23, indicated he was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality.) A review of Resident 52's Order Summary Report (a document summarizing a resident's current, active physician orders), dated 10/5/23, indicated on 3/16/23, Resident 52's prescriber ordered Seroquel 25 milligrams (mg - a unit of measure for mass) by mouth at bedtime every other day (every 48 hours) for psychosis manifested by visual hallucinations i.e., seeing insects in his food. A review of Resident 52's Medication Administration Record (MAR - a record of all medications administered to a resident) between 9/20/23 and 10/5/23 indicated Resident 52's was receiving Seroquel 25 mg every other day. A review of the consultant pharmacist's Medication Regimen Review (MRR - a monthly report completed by the consultant pharmacist to identify irregularities in a resident's medication regimen) recommendation, dated 9/3/23, indicated the consultant pharmacist made a recommendation to consider a gradual dosage reduction (GDR - a periodic attempt to reduce the dosage of a medication to the lowest effective dose or to discontinue the medication) for Resident 52's Seroquel and pimavanserin (a medication used to treat mental illness). Further review of this MRR recommendation indicated the prescriber responded on 9/20/23 indicating a GDR was clinically contraindicated (not recommended) because target symptoms returned or worsened after a past GDR and to reduce the dose of Seroquel to 25 mg by mouth every 72 hours. A review of Resident 52's psychiatric progress note (a document containing an assessment and plan for a resident's mental healthcare), dated 9/18/23 indicated the plan was to decrease Seroquel 25 mg every 72 hours. During an interview on 10/05/23 at 10:41 AM, the Director of Nursing (DON) stated when a GDR is performed due to a MRR request, the facility staff enters the new order in the MAR, discontinues the old order, and transmits the order to the pharmacy to be filled. DON stated the MRR, dated 9/3/20, received via fax from the prescriber on 9/20/23 indicated that the prescriber wanted to decrease the dose of Seroquel to 25mg every 72 hours. The DON stated the psychiatric progress note from 9/18/23 also indicated the plan was also to decrease the dose of Seroquel 25 mg from every 48 hours to every 72 hours. The DON stated when the prescriber indicates a plan to change a resident's dose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 28 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication, that change should be entered into the system immediately and the MAR should reflect the new dosage. The DON stated the facility failed to enter the new dosage for Resident 52's Seroquel on 9/20/23 or 9/26/23 (when the psychiatric progress note was received by the facility) and as a result Resident 52 is currently still receiving the old dosage of Seroquel 25 mg every 48 hours. The DON stated if Resident 52 received a higher dose of a Seroquel than necessary, it increases the risk that he may experience more adverse effects from that medication, like drowsiness, dizziness, or constipation, which could lead to a decline in his quality of life. During an interview on 10/05/23 at 10:48 AM, the Quality Assurance Nurse (QA) stated when new orders from a MRR recommendation come in via fax, she or other licensed staff is responsible to put the order into the resident's MAR right away. QA stated neither she nor any other licensed staff entered Resident 52's new order for a reduction in the dose of Seroquel into the MAR. QA stated there was some confusion concerning the prescriber's response to the MRR recommendation, dated 9/3/23, indicating that a decrease in dosage was contraindicated while also providing instructions to decrease the dosage of Seroquel which may explain why it was not entered. QA stated since the MRR recommendation addressed two medications, it is likely that the prescriber intended to maintain the dose of one and reduce the dose of the other, but it would need to be clarified with the prescriber. QA stated she and other licensed staff failed to clarify the order to understand the prescriber's intent. A review of the facility's undated policy Medication Orders, indicated Orders faxed (from the physician's office) . the following steps are initiated to complete the documentation: clarify the order . when a new order changes the dosage of a previously prescribed medication, discontinue(DC'd) the previous entry by writing DC'd and the date . enter the new order on the MAR . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 29 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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, and record review the facility failed to ensure five vials of pens of insulin (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 5, 14 and 17 in one of two inspected medication carts (West Station Cart 2.) The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 5, 14 and 17 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization. Findings: During a concurrent observation and interview on [DATE] at 1:37 PM of [NAME] Station Cart 2 with the Licensed Vocational Nurse (LVN 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened vial of Humulin R (a type of insulin used to treat high blood sugar) for Resident 5 was found stored at room temperature. According to the manufacturer's product labeling, unopened Humulin R vials must be stored in the refrigerator. 2. One unopened vial of insulin glargine (a type of insulin used to treat high blood sugar) for Resident 14 was found stored at room temperature. According to the manufacturer's product labeling, unopened vials of insulin glargine should be stored in the refrigerator. 3. One unopened vial of Humulin R for Resident 17 was found stored at room temperature. According to the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. 4. One unopened vial of Lantus (a type of insulin used to treat high blood sugar) was found stored at room temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 30 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 According to the manufacturer's product labeling, unopened vials of Lantus should be stored in the refrigerator. 5. One unopened Humulin N KwikPen (a type of insulin used to treat high blood sugar) for Resident 5 was found stored at room temperature. According to the manufacturer's product labeling, unopened Humulin N KwikPens should be stored in the refrigerator. LVN 2 stated the insulin for Residents 5, 14, and 17 are not stored properly according to the manufacturer's requirements. LVN 2 stated when insulin in unopened, it must remain in the refrigerator. LVN 2 stated she does not know why the insulin for Residents 5, 14, and 17 are stored in the medication cart. LVN 2 stated if insulin is stored at room temperature, the expiration date is shortened significantly and needs to be discarded much sooner. LVN 2 stated when insulin is stored improperly at room temperature, there is a risk of administering it to the resident once it has expired. LVN 2 stated administering expired insulin to residents could result in poor blood sugar control which could cause medical complications possibly leading to hospitalization. A review of the facility's undated policy Medication Storage in the Facility, indicated Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations . mediations requiring 'refrigeration' . are kept in a refrigerator with a thermometer to allow temperature monitoring . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 31 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident 55 was assisted and provided with additional nutritive packets to have a therapeutic diet (a prescribed meal plan that controls certain aspects of nutrients and/or foods as part of a treatment plan) as ordered by the physician during Restorative Nurse Assistant (RNA) feeding program (a feeding assistant program to restore residents to a former capacity or to improve their level of independence and thereby promote improved nutrition status) for one of three sampled residents (Resident 55). Residents Affected - Few This failure had the potential to result in preventing Resident 55 from receiving benefit of a therapeutic diet. Findings: During a review of Resident 55's admission record, the admission record indicated Resident 52 was admitted to the facility on [DATE]. Resident 55's diagnosis included atrial fibrillation (an irregular and often very rapid heart rhythm), dysphagia (difficulty swallowing), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and cerebral infarction (a loss of blood flow to part of the brain). During a review of Resident 55's History and Physical (H&P), dated 8/17/2023, the H&P indicated, Resident 55 did not have the capacity to understand and make decisions. During a review of Resident 55's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/17/2023, the MDS indicated Resident 55 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision and setup help for eating. During a review of Resident 55's Order Summary Report , Order Summary Report dated 10/5/2023, theOrder Summary Report indicated, fortified diet with pureed texture, thin liquid consistency and large portion diet was ordered on 9/25/2023. Order Summary report also indicated RNA feeding program with breakfast and lunch ordered on 9/7/2023. During a review of Resident 55's Care Plan (CP), dated 9/7/2023, the CP focus indicated, Resident 55 required RNA feeding program with breakfast and lunch. The CP interventions indicated, RNA provide verbal cues such as take a bit or pick up the spoon. During a review of Resident 55's Care Plan (CP), dated 8/15/2023, the CP focus indicated, Resident 55 was at risk for altered nutritional status. The CP intervention indicated, provide diet as ordered: fortified diet, pureed texture, thin liquid consistency, large portion diet. During a concurrent observation and interview on 10/4/2023, at 12:12 p.m., with RNA 1, at Rehabilitation RNA dining room, Resident 55 was sitting on chair and waiting for his tray. RNA 1 brought tray for Resident 55. The tray ticket indicated, fortified (The addition of nutrients to food, food constituents, or supplements) puree (foods that are smooth and lump free) diet. There was one sugar packet and two margarine packets on the tray. RNA 1 did not add any of them into Resident 55's food. There was no gravy on mashed potatoes, and no melted butter on pureed spinach. Resident 55 grabbed the spoon and started eating with his left hand. Resident 55 stated, all items on tray were dry. RNA 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 32 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was observed to got up from her chair and left. RNA 1 stated, she left because Resident 55 was able to feed himself. RNA 1 stated, she did not know what the fortified diet was. RNA 1 stated, she did not add sugar packet and margarine packets into Resident 55's food because he did not ask to add. RNA 1 stated, she did not know where to get the list of residents who were receiving RNA feeding assistance. During an interview on 10/5/2023, at 12:51 p.m., with Assistant Director of Nursing (ADON), ADON stated, she oversaw RNA feeding program. ADON stated, RNA should know the different types of physicians prescribed diets (therapeutic diet). ADON stated, if there were items to add such as butter packets or margarine packets to increase calorie on food, RNA should be able to recognize fortified items and add to the resident's food. ADON stated, RNA should stay with the resident entire mealtime and should not leave the resident during mealtime. ADON stated, if the resident did not get the fortified diet as ordered, it would affect the resident with undesired weight loss. During a concurrent interview and record review on 10/4/2023, at 2:45 p.m., with Registered Dietitian (RD), Resident 55's Clinical Recommendations (CR), dated 9/5/2023, was reviewed. The CR indicated, Resident 55 lost seven pounds in three weeks and RD recommended RNA feeding program for breakfast and lunch. RD stated she recommended RNA feeding program so Resident 55 could get proper diet to gain back the weight he lost. During a review of the facility's Lesson Plan for RNA Feeding Program (LP RNA FP), undated, the LP RNA FP indicated, RNA supervised, monitored, and assisted residents who needed feeding assistance to ensure that they consume the required calories and to prevent weight loss. During a review of the facility's Fortified Menu Plan (FMP), undated, the FMP indicated, fortified diet plan added from 300 to 400 calories and from three to four grams of protein per day. The FMP indicated, fortified items for starch menu (such as mash potatoes) were extra half ounce melted margarine, one table spoon of puree shredded cheese, and 1 table spoon of sour cream. The FMP indicated, fortified items for vegetable menu were extra half ounce melted margarine or one table spoon of puree shredded cheese. During a review of the facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the diet, dated 2018, the P&P indicated, Purpose: The goal is to increase the calorie and /or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status .General considerations .Residents usually eat the same amount of food whether it is fortified or not. Therefore, fortification should increase nutrient density without increasing the amount of food sent. During a review of the facility's policy and procedure (P&P) titled, RNA Feeding Program, undated, the P&P indicated, Policy . A restorative feeding/dining program, as part of the Facility Restorative program will be provided in order to restore residents to a former capacity or to improve their level of independence and thereby promote improved nutrition status. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, undated, the P&P indicated, Policy Statement: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation . 4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 33 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide proper adaptive eating utensils (AE, eating equipment such as forks, knives, and spoons that are modified to increase independence with eating) for one of seven sampled residents (Resident 69) by failing to: Residents Affected - Few 1. Follow physician's orders for AE. 2. Perform an assessment to determine the AE provided to Resident 69 was suitable and effective. These deficient practices resulted in Resident 69 being issued built-up utensils (eating utensils with large handles made from hard plastic or soft foam to allow a person with limited grasp or hand strength to hold utensils with more ease) instead of weighted utensils (eating utensils with large handles with weights inside that help reduce tremors and improve control while eating) per physician's order for meals and had the potential to cause weight loss, decreased independence with self-feeding, and decreased quality of life. Findings: A review of Resident 69's admission Record indicated the facility admitted Resident 69 on 7/20/2021. Resident 69's diagnoses included right sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and muscle weakness. A review of Resident 69's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 7/27/2023, indicated Resident 69 was severely impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 69 required extensive assistance with eating, dressing, personal hygiene, and bed mobility and was totally dependent with transfers (how resident moves between surfaces including to or from bed, chair, wheelchair and standing position), toileting, and bathing. The MDS also indicated Resident 69 had range of motion (full movement potential of a joint) limitations in one arm (shoulder, elbow, wrist, hand) and one leg (hip, knee, ankle, foot). A review of Resident 69's Order Summary Report, dated 3/3/2022, indicated for Resident 69 to have weighted utensils every meal to improve independence with self-feeding. A review of Resident 69's Comprehensive Care Plan, initiated 3/3/2023, indicated Resident 69 was at risk for altered nutritional status and significant weight changes. The interventions included providing weighted utensils with every meal to improve independence with self-feeding. 1. During an observation and interview on 10/5/2023 at 12:22 pm, in Resident 69's room, Resident 69 was observed sitting in a recliner chair with a bedside table and meal tray placed directly in front (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 34 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the body and at waist level. Certified Nursing Assistant 7 (CNA 7) was sitting in a chair to the left of Resident 69. The meal tray contained a plate divided into three sections with rice, meat, and an orange mashed potato like food. Three utensils (one fork, one spoon, and one knife) with red, thick handles were on the meal tray. Resident 69 drank fluid from a sippy cup (cup with a lid and a spout designed to reduce spills) using the left hand. CNA 7 handed Resident 69 the spoon with the red, thick handle and Resident 69 scooped the food from the tray with the left hand and fed self with assistance from CNA 7. The meal ticket on the tray indicated Resident 69's meal tray should have included built up utensils, a divided plate, and a sippy cup. CNA 7 confirmed Resident 69 was using built up utensils to eat, not weighted utensils. During an interview and record review of Resident 69's Physician's Orders on 10/5/2023 at 2:03 pm, Licensed Vocational Nurse 3 (LVN 3) confirmed Resident 69 had a physician's order for weighted utensils for every meal. LVN 3 stated Resident 69 should have received weighted utensils instead of built-up utensils because the physician ordered weighted utensils. LVN 3 stated the CNA or LVN was supposed to compare and ensure the meal ticket items matched the physician's order prior to feeding the resident. LVN 3 stated that if the meal ticket items did not match the physician's order, nursing must always follow the physician's orders regardless of what the kitchen provided. LVN 3 confirmed the AE on Resident 69's meal ticket for built up utensils did not match the physician's order for weight utensils and should not have been given to Resident 69. LVN 3 stated it was important residents receive the correct AE because it could decrease their independence with self-feeding. During an interview on 10/5/2023 at 2:20 pm, the Director of Nursing (DON) stated nursing must follow the physician's orders for AE. The DON stated it was important for residents to receive the correct AE during meals because it affected their level of independence with feeding. During an interview on 10/6/2023 at 11:36 am, the Dietary Supervisor (DS) confirmed the kitchen staff did not follow physician's orders when providing Resident 69 with AE for all meals. The DS confirmed the utensils with the red, thick handles were built up utensils and the utensils with the thick grey handles were weighted utensils. The DS stated the kitchen had been providing Resident 69 with built up utensils, not weighted utensils per physician's order for a very long time because the type of AE manually inputted onto the meal ticket was incorrect. 2. During an interview on 10/5/2023 at 10:00 am, the Director of Rehabilitation (DOR) stated Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) assessed the resident's need for AE. The DOR stated the OT notified the Director of Nursing (DON), Assistant Director of Nursing, or Quality Assurance Nurse of the specific type of AE recommended based on the resident's needs and nursing called the doctor to write an order. During an interview on 10/5/2023 at 2:20 pm, the DON stated a clinical assessment for AE must be completed by an OT prior to issuing AE to any resident in the facility. The DON stated no other service in the facility would be able to complete an assessment and provide recommendations for the type of AE a resident needs because it was OT's specialty area. The DON stated that if AE was no longer suitable for a resident, OT would need to complete another assessment, update the recommendations for the proper AE for the resident, and obtain a new physician's order. The DON stated that if a resident received AE without a clinical assessment to ensure it was suitable for their needs, the AE may not be effective and would make the resident more dependent on others for care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 35 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/6/2023 at 8:45 am, the DOR stated he could not find any documented evidence from OT to indicate that Resident 69 was assessed for AE and did not know who recommended Resident 69 use weighted utensils for all meals. During a follow up interview with the DOR on 10/6/2023 at 9:25 am, the DOR stated if a resident was not assessed for the proper AE or used AE other than what was recommended by OT, it could potentially cause weight loss, agitation, depression, deconditioning (decline in physical function due to physical inactivity) due to malnutrition (lack of sufficient nutrients in the body), decreased quality of life, and decreased fine motor skills (ability to make precise movements using small muscle groups). During an interview on 10/6/2023 at 9:38 am, the Administrator stated the facility did not have a policy for AE. A review of the facility's Policy and Procedure (revised March 2018) titled, Activities of Daily Living (ADL), Supporting indicated residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. The P/P further indicated residents who were unable to carry out their ADLs independently would receive the necessary services to maintain good nutrition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 36 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Residents Affected - Some 1.Cooked eggs, cooked bacon and ready to eat tofu were stored on the same shelf next to raw eggs and a carton of raw liquid eggs. Raw chicken was stored to thaw on shelf above raw marinated ground beef. This had the potential to cross contaminate food and result in food borne illness in 100 residents who received food from the kitchen. 2.Kitchen wash cloths/towel were stained and discolored, and dishware were chipped. Staff using discolored and stained wash cloths to clean food contact surfaces. 3.Cook1 did not wash hands after removing soiled gloved and returned to food prepare vegetables and rice. Dishwasher staff working in the dish machine area did not wash hands after changing gloves and when removing the clean and sanitized dishes from the dish machine. 4.Ice machine was not maintained in a sanitary manner and the inside compartment of ice machine was stained and dirty. 5. Food brought to residents from outside of the facility, including leftovers were stored in the resident food refrigerator were not labeled and dated. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 100 out of 104 residents who received food and ice from the facility and including three residents who had food stored in the resident refrigerator. Findings: 1.During an observation in the kitchen on 10/3/23 at 8:30AM, there was a container of hard-boiled eggs stored on same shelf next to raw shelled eggs and a carton of open liquid eggs in the reach in refrigerator. Cooked bacon on a tray and ready to eat tofu was also stored on the same shelf. During a concurrent observation and interview with Dietary Supervisor (DS), DS said it was left over from breakfast and cooked food should be stored separately to prevent cross contamination. During and observation in the walk-in refrigerator on 10/3/23 at 8:40AM, there was raw chicken thawing on top of marinated ground beef. The ground beef was in a large bowl and loosely covered with a plastic wrap. During a concurrent observation and interview DS said chicken should be thawing on the bottom shelf to prevent juices from contaminating other meat products. DS reviewed the facility policy for food storage and said chicken should be stored on bottom shelf to prevent cross contamination and removed the meats. A review of facility policy titled Food Preparation (Dated 2018), indicated, keep raw and cooked foods separate. Store raw meat, poultry, and fish in the order from top to bottom .a. whole fish, b. whole cuts of beef and pork, c. Ground meat and fish, d. whole and ground poultry. 2.During an observation in the kitchen on 10/3/23 at 9:15AM, Cook1 was using kitchen dish cloths to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 37 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 wipe and clean the counter for food preparation. The dish cloths were wet and were stored on the food preparation counters, Cook1 was using the same dish cloth to repeatedly wipe the counter after food preparation. The kitchen cloths looked stained and discolored grey in color. During concurrent observation and interview, cook1 said that the dish cloths are used to clean surfaces, [NAME] 1 said that he dips the dish cloth in the sanitizer bucket and wipes the surfaces. Cook1 said it should be inside the red sanitizer bucket, but he left them outside on the counter because he uses them often. During the same interview, Dietary Supervisor (DS) said that some of the kitchen wash cloths are discolored and will be replaced. DS said the dish cloth should always be stored in the sanitizer bucket inside the sanitizer solution when not in use for adequately sanitizing surfaces. During a tray line lunch service observation on 10/3/23 at 11:50AM, observed 5 dishes were chipped and cracked on the sides. Cook1 continued to serve food to residents on chipped dishes. During a concurrent observation and interview DS removed the chipped dishes from service and said chipped dishes should be discarded because it can not be cleaned and sanitized. A review of facility policy titled sanitation (dated 2018) indicated, all utensils, counters, shelves and equipment shall be kept clean, maintained in a good repair and free from .cracks and chipped areas. A review of the 2022 U.S. Food and Drug Administration Food Code, Code 4-202.11 Food-Contact Surfaces, indicated, A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; and (2) Laundered daily as specified under 4-802.11(D). (C) Cloths in-use for wiping surfaces in contact with raw animal FOODS shall be kept separate from cloths used for other purposes. 3.During an observation in the food preparation area on 10/3/23 at 9:30AM, Cook1 was marinating and adding seasoning to raw chicken in a bowl. Cook1 had gloves on his hands and was mixing the chicken with hands. After finishing the chicken preparation, cook1 removed the soiled gloves and returned to the food preparation counter without washing his hands. [NAME] 1 proceeded to place the chicken in a pan and in the oven. Then Cook1 continued to prepare other food items. During a concurrent observation and interview, Cook1 said that he forgot to wash his hands after he removed the gloves. He said that he could contaminate everything that he touched after removing the gloves. During an observation in the dishwashing area on 10/3/23 at 9:40AM, Dishwasher (DW1) was rinsing soiled dishes and loading the dirty dishes in the dish machine. DW1 had gloves on his hands, and after the dish machine stopped DW1 wore new gloves without washing hands and proceeded to remove the clean and sanitized dishes from the dish machine without washing hands. During a concurrent interview, DW1 stated he didn't wash his hands after removing gloves and before touching the clean dishes. DW1 sated not washing hands can contaminate clean dishes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 38 of 43 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 056164 B. Wing (X3) DATE SURVEY COMPLETED A. Building 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 During an interview with DS on 10/3/23 at 9:50AM, DS said that in the afternoon there is two Dishwasher, and one handles the soiled dishes, and the other dishwasher assists with removing sanitized dishes. A review of facility policy titled sanitation (dated 2018), indicated, A minimum of two employees will be used when dishes are machine washed. One will handle soiled area and ne will handle the clean side. If an employee does need to go from soiled end to clean end, a strict hand washing routine must be followed. A review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 When to Wash. Indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and E) After handling soiled EQUIPMENT or UTENSILS. (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD. (H) Before donning gloves to initiate a task that involves working with FOOD. 4.During an observation of the facility ice machine on 10/3/23 at 1:05PM, located in the small dining room, a clean paper towel swipe of the ice storage bin ceiling produced small amounts of black residue. The residue was located under the baffle (plastic board that hold the ice from falling out of the ice storage bin). The baffle also had black color stains and discoloration. During a concurrent interview with Maintenance Supervisor (MS), MS stated that it's his responsibility to clean the filters and outside of the ice machine. MS stated that an ice machine vendor cleans the inner compartments of the ice machine. During a concurrent review of the ice machine cleaning log, it indicated that outside vendor had cleaned on 8/9/23. MS verified that there was black residue inside the ice machine and said he will contact the vendor. A review of facility policy titled sanitation (dated 2018), indicated, Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. 5.During an observation in the resident refrigerator located in the conference room on 10/4/23 at 10:30AM, there was chicken and vegetable in a plastic container, a plastic bag full of several different soups, sandwiches, and snack with only resident room number on the bag, there was no date. There were several bags of food with no name and date and There was another container of food for a resident who is no longer at facility. During a concurrent interview with LVN5, she stated that nurses check the food brought from visitors for diet compatibility. LVN5 said that facility stores food for 3 days and then discard. LVN5 said it's important to label and date to know when to discard food. LVN5 didn't know when the food was stored in this refrigerator and said food will be discarded because there is no date on them. A review of facility policy titled Foods brought by family/visitors (revised 10/2017) indicated, Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 39 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 container will be labeled with the resident name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 40 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the electric hi-low therapy mat (therapy mat, electric and adjustable padded mat table used for therapy treatments) was in safe, operating condition. Residents Affected - Some This deficient practice had the potential to cause injury to any resident or staff member who used this equipment as part of therapy treatment. Findings: During an observation on 10/4/2023 at 2:55 pm, in the rehab gym, a padded therapy mat was observed against the window of the rehab gym. The button controls to adjust the therapy mat height up and down were centered and attached to the base of the therapy mat frame. During an observation and interview on 10/5/2023 at 10:00 am, in the rehab gym, the Director of Rehabilitation (DOR) who was also a Physical Therapist(PT- movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education) confirmed the height of the therapy mat could not be adjusted because it was broken. The DOR stated the therapy mat was always left unplugged because the motor that controlled the height of the mat did not work. The DOR stated maintenance tried to fix the therapy mat several times, but it still did not work. During an interview on 10/5/2023 at 11:24 am, the Maintenance Supervisor (MS) stated the therapy mat was broken. The MS stated the motor that powered the therapy mat to go up and down was broken. The MS stated he tried to fix the therapy mat multiple times, but it was still broken and did not know why the facility did not throw it away. The MS stated the facility decided to use the therapy mat as a standard mat table (static platform with a padded surface used for therapy treatments) since the motor was broken instead of trying to fix it or replace it. During a follow up interview on 10/5/2023 at 12:43 pm, the DOR stated the therapy mat was still used for therapy treatments despite being broken because it was the only therapy mat the facility had. The DOR stated it was important to have equipment that was maintained in safe, operating order for patient safety, staff safety, and injury prevention. During an interview on 10/5/2023 at 1:54 pm, the Occupational Therapist (OT 1) stated she was told the therapy mat was broken and could only use the therapy mat as a standard, non-adjustable mat for therapy treatments. OT 1 stated hi-low therapy mats were useful in therapy treatments because they allowed the therapist to adjust the height of the mat to assist with different types of transfers (an act of moving something or someone to another place) and improved staff safety. During a follow up interview on 10/6/2023 at 11:45 am with the MS, the MS stated the therapy mat tilted and became unstable if the motor was turned on. The MS stated the therapy mat had been broken for almost one year and should have been replaced if it was broken and unfixable. The MS stated there could be potential harm to the staff and residents if the facility continued to use broken equipment during therapy treatments. A review of the facility's undated Policy and Procedure (P/P) titled, Therapy Rooms, Equipment and Supplies, indicated Therapists are responsible for maintaining assigned equipment in a safe, clean, and usable manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 41 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm A review of the facility's undated P/P titled, Assistive Devices and Equipment, indicated device condition would be addressed to decrease the risk of avoidable accidents associated with equipment. The P/P indicated Defective or worn devices will be discarded or repaired. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 42 of 43 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) were provided mandatory (required by law or rules) minimum 12 hours per year in-service training of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) Care and Abuse (treat a person with cruelty or violence, especially regularly or repeatedly). This failure had the potential to result in the residents being subject to abuse, and residents who had dementia improperly cared for. Findings: During a concurrent interview and record review on 10/6/2023, at 4:38 p.m., with Director of Staff Development (DSD), CNA 8's In-Service Attendance Log for Abuse and Dementia Care (IALAD), dated from 1/2022 to 10/2023 was reviewed. The IALAD indicated, there were four abuse in-service trainings done on 2/17/2022, 5/18/2022, 7/7/2022, 12/5/2022 and three dementia care in-service trainings done on 3/15/2022, 4/21/2022, 9/8/2022. The IALAD indicated, there were five abuse in-service trainings done on 1/19/2023, 4/6/2023, 5/4/2023, 6/15/2023,7/13/2023 and one dementia care in-service training done on 1/12/2023. DSD stated abuse and dementia care in-service trainings were mandatory for CNAs and CNAs must receive two to four hours of both trainings per year. DSD stated, CNAs had an option to attend both trainings beyond four hours per year if they wanted to. DSD stated each session was done for one hour. DSD stated total mandatory trainings totaled 7 for the year 2022. During a concurrent interview and record review on 10/6/2023, at 5:52 p.m., with DSD, the facility's In-Service Calendar (IC) for 2023 was reviewed. The IC indicated, abuse in-service was scheduled for 7/13/2023, 8/17/2023, 10/5/2023,11/9/2023 and dementia care in-service was scheduled for 1/12/2023. DSD stated, she noticed she did not follow the in-service calendar, but it would be ok if she completed 4 hours per year mandatory trainings. DSD stated, she found abuse and dementia care training records on 10/11/2017, but she could not find any records from 2018 to 2021. DSD stated, she had no evidence to prove the facility provided abuse and dementia care training from 2018 to 2021 to CNA 8. DSD stated those mandatory trainings were essential to provide better care for the residents. During an interview on 10/6/2023, at 6:42 p.m., with Administrator (ADM), the ADM stated, he was not sure how many hours were required for abuse and dementia care training, but he believed it should be more than four hours. ADM stated the mandatory trainings were very important because all residents were being subjects to abuse and many of them were diagnosed with dementia. During a review of the facility's Facility Assessment (FA), dated 4/21/2023, the FA indicated, Individual Staff Assignment .Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 43 of 43