Health inspection·December 6, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the POLST dated [DATE], Section A (CPR) showed Resident 533's family member had selected Do Not Attempt Resuscitation. Section D (Information and Signatures) showed Resident 533 had an Advanced Directive dated [DATE]. Review of Resident 533's Order Summary Report dated [DATE], showed a physician's order dated [DATE], to not attempt resuscitation. On [DATE] at 1547 hours, a medical record review was conducted for Resident 533. Resident 533's medical record failed to show a copy of the Advance Directive was obtained and maintained in the medical record. On [DATE] at 1452 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the above findings. On [DATE] at 1542 hours, an interview was conducted with the Medical Records Director. The Medical Records Director verified the Advanced Directive was missing from Resident 533's original medical record. On [DATE] at 1624 hours, an interview was conducted with the DON. The DON stated the social services staff was responsible for making sure the Advanced Directive was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 2 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 18 final sampled residents (Resident 75) attained and maintained their highest practicable physical well-being. Resident 75 had a recent left total knee arthroplasty (knee replacement). The facility failed to follow the physician's order to apply the left knee immobilizer (device to temporarily immobilize, stabilize, and protect an injured or post-surgical knee) to Resident 75 while in bed. This posed the risk of Resident 75 not being able to maintain knee extension following the surgery. Residents Affected - Few Findings: On 12/3/19 at 1300 hours, during the initial tour of the facility, Resident 75 was observed seated in bed. A CPM (continuous passive motion, a machine used to move a joint without the resident having to exert any effort) and an ice machine were observed at Resident 75's bedside, but were not applied to Resident 75. Resident 75 stated she recently had surgery on her left knee. Medical record review for Resident 75 was initiated on 12/3/19. Resident 75 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 11/15/19, to apply the knee immobilizer to Resident 75's left knee while she was in bed (except when the CPM was on) to facilitate knee extension. Review of Resident 75's plan of care showed a care plan problem dated 11/15/19, to address Resident 75's self-care deficit related to recently having a left total knee arthroplasty. The interventions included to apply the knee immobilizer to Resident 75's left knee while she was in bed to facilitate knee extension. Review of the MDS dated [DATE], showed Resident 75 was cognitively intact. Review of the Physical Therapy Treatment Encounter Note(s) dated 12/3/19, showed under precautions, Resident 75 had a surgical site to the left knee and was status post total knee replacement. The precautions included to apply the left knee immobilizer while Resident 75 was in bed. On 12/3/19 at 1450 hours, and on 12/4/19 at 0708 and 0825 hours, Resident 75 was observed in bed with no knee immobilizer in place. The CPM was at Resident 75's bedside, but was not applied to Resident 75. On 12/4/19 at 0833 hours, an observation of Resident 75 was conducted with the Infection Preventionist. The Infection Preventionist verified Resident 75 had no knee immobilizer in place. After checking Resident 75's closet, the Infection Preventionist stated the knee immobilizer was in the closet. Resident 75 stated the staff only applied the knee immobilizer to her left knee the first week she was admitted to the facility and had not been offering to apply the knee immobilizer since. On 12/4/19 at 0840 hours, an interview and concurrent medical record review was conducted with the Infection Preventionist. The Infection Preventionist verified Resident 75 was supposed to have the left knee immobilizer in place when the CPM was not on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 3 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for one of 18 final sampled residents (Resident 433). Resident 433 was admitted to the facility with multiple pressure ulcers to the feet, including the bilateral heels, the right first metatarsal head, and the left fifth metatarsal head. The facility failed to ensure Resident 433's heel protectors were applied as ordered by the physician. This had the potential of Resident 47 not receiving the appropriate care and services to promote healing of the pressure ulcers. Residents Affected - Few Findings: Medical record review for Resident 433 was initiated on 12/3/19. Resident 433 was admitted to the facility on [DATE]. Review of the Baseline Admission/readmission Screening dated 11/20/19, showed Resident 433 was admitted to the facility with deep tissue pressure injuries (DTI) to the right first metatarsal head and the left and right heels and a Stage 2 pressure injury to the left fifth metatarsal head. Review of the Order Summary Report showed two physician's orders dated 11/20/19, to apply the left and right heel protectors to Resident 433 and have them in place at all times. Review of Resident 433's plan of care showed care plan problems dated 11/21/19, to address the multiple pressure ulcer sites to Resident 433's feet. The interventions included to apply the heel protectors as ordered. On 12/3/19 at 1400, 1442, and 1628 hours, and on 12/4/19 at 0709, 0938, 1051, and 1132 hours, Resident 433 was observed in bed with no heel protectors in place. On 12/4/19 at 1133 hours, an observation of Resident 433 was conducted with LVN 2. LVN 2 verified Resident 433 did not have heel protectors in place. LVN 2 stated the wound care nurse was supposed to apply the heel protectors. On 12/4/19 at 1138 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified the physician's orders showed Resident 433 was supposed to have heel protectors in place. LVN 5 stated the CNAs were responsible for applying the heel protectors. LVN 5 stated Resident 433 sometimes refused or kicked off the heel protectors after they were applied. After reviewing Resident 433's medical record, LVN 5 verified there was no documentation to show Resident 433 refused the heel protectors and the physician was notified Resident 433 refused the heel protectors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 4 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 37) remained free from accident hazards. * The facility failed to implement the physician's order and care plan interventions to prevent falls and reduce fall injuries after Resident 37 sustained a fall while at the facility. The facility failed to implement a sensor pad alarm (a sensor pad placed in the wheelchair seat or in the bed which will emit an alarm if the resident moves off the pad) while in the wheelchair as ordered by the physician after Resident 37 sustained a fall. This failure posed the risk for additional falls and injuries to the resident. Findings: On 12/4/19 at 0958, 1137, and 1406 hours and on 12/5/19 at 0710 hours, Resident 37 was observed in the wheelchair with a Tab alarm (a box-shaped alarm unit. An adapter which fits into the alarm box has a string with a clip which attaches on to the person's clothing on their shoulder. When the resident begins to move, the string with the adapter pulls loose from the alarm box and causes the alarm to sound). The Tab alarm was attached to the top portion of the wheelchair's backrest and the adapter with the string was clipped to Resident 37's clothing at the left upper shoulder area. Review of the medical record for Resident 37 was initiated on 12/3/19. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the IDT Notes dated 10/2/19, showed Resident 37 had a fall incident and had a right humerus (the bone in the upper arm) fracture. Resident 37 was transferred to the hospital due to the fracture. One of the recommendations after the fall incident was to place a bed and wheelchair alarms. Review of Resident 37's Order Summary Report showed an order dated 10/9/19, to apply the sensor pad alarm while in the wheelchair to alert staff when the resident attempted to get up unassisted, and monitor placement and function. Review of Resident 37's plan of care showed a care plan problem to address an actual fall related to an episode of getting up from the wheelchair without asking for assistance. The interventions included use of a sensor pad alarm while up in the wheelchair to alert staff when Resident 37 attempted to get up unassisted. On 12/5/19 at 0952 hours, an observation, interview, and concurrent medical record review was conducted with RN 2. Resident 37 was observed in the physical therapy department. Resident 37's wheelchair had a Tab alarm attached to the top portion of the wheelchair's backrest. RN 2 was asked if the physician's order was for the use of a Tab alarm. RN 2 stated yes. After review of the physician's order for Resident 37, RN 2 verified the physician's order showed to apply a sensor pad alarm while in the wheelchair. When RN 2 was asked the purpose for the use of the alarm, RN 2 stated the alarm was to alert staff when Resident 37 tried to get up from his wheelchair; to prevent falls. RN 2 was asked the difference between the Tab alarm and the sensor pad alarm. RN 2 stated the Tab alarm sounded when the string attached to the adapter for the Tab alarm was pulled when the resident attempted to get up. RN 2 was asked how far the resident had to be up off the wheelchair in order for the alarm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 5 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sound. RN 2 stated it depended on the length of the string from the alarm. RN 2 stated the sensor alarm would sound as soon as the pressure was off the pad. RN 2 stated the facility should have applied the sensor pad alarm as ordered by the physician instead of the Tab alarm. On 12/5/19 at 1006 hours, observation and interview was conducted with the PT and RN 2. Resident 37 was observed receiving physical therapy. When Resident 37 sat in his wheelchair, RN 2 clipped the string of the Tab alarm to Resident 37's clothing at the upper shoulder area. Resident 37 was getting up with assistance by the PT. The Tab alarm started to sound after Resident 37 completely stood up, causing the adapter to be pulled from the alarm box. On 12/5/19 at 1030 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 37 had been using a Tab alarm while in his wheelchair instead of the sensor pad alarm the physician ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 6 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 48) received the accurate amount of enteral feeding (nutrition delivered directly to the stomach using a tube). This posed the risk of the resident's nutritional needs not being met. Findings: On 12/4/19 at 0813 and 1306 hours, Resident 48 was observed lying in bed. A tube feeding pump on a pole was observed next to the bed. No tube feeding was being administered. Medical record review for Resident 48 was initiated on 12/4/19. Resident 48 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 7/26/19, for Glucerna 1.2 (enteral feeding) at 50 ml per hour times 18 hours to provide 900 ml/1080 calories or until dose limit is met. Review of the Medication Administration Record for December 2019 showed the enteral feeding was scheduled to be given at 50 ml per hour daily, starting at 1500 hours and off at 0900 hours. On 12/4/19 at 1425 hours, an interview and concurrent observation was conducted with LVN 1. LVN 1 verified the enteral feeding was turned off earlier than the scheduled time because Resident 48 had to be provided her shower. LVN 1 checked the pump and verified Resident 48 only received 563 ml of enteral feeding the past 25 hours. LVN 1 stated this was due to the GT had to be replaced yesterday. When asked if the physician was informed Resident 48 did not receive the total volume of enteral feeding, LVN 1 stated no. On 12/5/19 at 0903 hours, a telephone interview was conducted with Physician 1. Physician 1 stated the licensed nurses should notify the physician whenever an enteral feeding was not provided as ordered. In this case, the licensed nurses should have extended the feeding until the dose limit was met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 7 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pharmacy services for one of 18 final sampled residents (Resident 35). The licensed nurse failed to properly administer an inhaler medication to Resident 35. This had the potential of Resident 35 not receiving the therapeutic level of medication. Findings: Review of the facility's P&P titled Oral Inhalation and Administration dated 4/2008 showed, if the residents receive an inhaler containing a steroid, the licensed nurses should instruct the residents to rinse their mouths with water and spit out after final dose. According to the Lexicomp (a drug resource for healthcare professionals) regarding how to administer budenoside-formoterol aerosol, the nurse should instruct the resident to place the mouthpiece gently between the teeth, closing lips around the inhaler, inhale deeply, press the top counter, and hold their breath for up to 10 seconds or as long as they comfortably can, remove the mouthpiece from the mouth prior to exhalation. A resident should not breathe out through the mouthpiece. Wait more than 30 seconds prior to the second inhalation dose. Then the resident should rinse their mouth with water (spit out without swallowing) after each use. Medical record review for Resident 35 was initiated on 12/4/19. Resident 35 was admitted to the facility on [DATE], with diagnoses including COPD (chronic obstructive pulmonary disease). Review of the Order Summary Report dated 12/6/19, showed a physician's order dated 12/5/19, to administer budenoside-formoterol aerosol 160-4.5 mcg/ACT (an inhaler containing a steroid), two puffs via inhaler orally two times a day; rinse mouth with water after use. The licensed nurse was to hand the inhaler to Resident 35, and Resident 35 may self-administer with nurse's instructions and supervision. On 12/5/19 at 0820 hours, LVN 1 was observed administering budenoside-formoterol aerosol inhaler to Resident 35. LVN 1 handed the canister to Resident 35. Resident 35 was observed administering two puffs of the inhaler consecutively without waiting 30 seconds between puffs. LVN 1 was observed providing a cup of water to Resident 35 and asked Resident 35 rinse her mouth. Resident 35 was observed rinsing her mouth two times and swallowing water after each rinse. On 12/5/19 at 0830 hours, an interview was conducted with LVN 1. LVN 1 was informed of the observation of Resident 35 not waiting 30 seconds between the two puffs and swallowing the water after each rinse. LVN 1 verified she did not supervise Resident 35 administering the inhaler medication properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 8 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure four of 18 final sampled residents (Residents 19, 37, 11, and 42) were free from unnecessary psychotropic medications. * Resident 42 was receiving Seroquel (antipsychotic medication) even though he had not manifested a single behavior episode for two years. The facility failed to ensure Resident 42's orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) was monitored as ordered by the physician related to the use of Seroquel. These failures had the potential for the resident to experience adverse consequences from the antipsychotic medication. * Resident 37 was receiving Remeron (antidepressant medication) for depression manifested by poor meal intake of less than 76%. The facility failed to accurately monitor the number of episodes in which Resident 37's meal intake was less than 76%. This posed the risk of Resident 37's physician not having the necessary information to determine the effectiveness of the Remeron. * Resident 11 was receiving Depakote (anticonvulsant also used as adjunct therapy for behavior problems) for mood lability manifested by moaning for no reason. The facility failed to accurately monitor the number of episodes in which Resident 11's moaning behavior was exhibited. This posed the risk of Resident 11's physician not having the necessary information to determine the effectiveness of Depakote. * The facility failed to ensure Resident 19's orthostatic blood pressure was monitored as ordered by the physician related to the use of Risperdal (antipsychotic medication). This failure had the potential for the resident to experience adverse consequences from the antipsychotic medication. Findings: 1. On 12/3/19 at 1402 hours, and 12/4/19 at 0805 hours, Resident 42 was observed lying in bed, asleep, and was not responsive. Medical record review for Resident 48 was initiated on 12/4/19. Resident 42 was admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE], showed Resident 42 had severe cognitive impairment. Review of the Order Summary Report showed a physician's order dated 12/1/19, for Seroquel 25 mg, give one tablet via GT at bedtime for psychosis manifested by unprovoked striking out towards staff; and an order dated 11/16/17, to monitor for orthostatic hypotension every Friday by checking the blood pressure in three positions (lying, sitting, and standing). Resident 42 had been administered the Seroquel tablet for behavior manifestation of striking out to staff since 11/4/17. a. Review of the Psychotropic Summary Sheet showed a monthly summary of Resident 42's behavior of striking out related to the use of Seroquel. The summary showed Resident 42 did not have any behavior of striking out since 12/4/17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 9 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Behavior Management Follow Up dated 3/21, 6/14, 8/15, and 10/17/19, showed repeated recommendations from the psychiatrist and the IDT for a dose reduction of Seroquel due to stable behavior. However, Resident 42's primary care physician declined the repeated recommendations. On 12/4/19 at 0956 hours, an interview was conducted with CNA 3. CNA 3 stated he had not seen Resident 42 with behavior of striking out at staff. On 12/5/19 at 0722 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 42 had not manifested any behaviors recently. When asked what behaviors Resident 42 had, LVN 1 stated Resident 42 pulled his GT. LVN 1 stated she had not seen Resident 42 with a behavior of striking out at staff. On 12/5/19 at 0833 hours, a telephone interview was conducted with Physician 1. Physician 1 stated Resident 42 had been on Seroquel for years. Physician 1 was asked if he was aware Resident 42 did not have any behavior manifestation of striking out at staff for two years. Physician 1 stated Resident 42 continued to strike out, but, the nursing staff did not document it because it was so minor. Physician 1 stated he declined the repeated recommendations of the psychiatrist to reduce the dose of Seroquel because Resident 42 was still manifesting behaviors. Physician 1 stated he was not aware of the licensed nurses monitoring of Resident 42's behavior. Physician 1 stated he knew if he discontinued the medication, Resident 42 would have behaviors. When asked if he tried discontinuing the medication before, Physician 1 stated no. When asked what behaviors Resident 42 had, Physician 1 stated he pulled his GT. When asked if he was aware Resident 42 was observed to be sleeping a lot, Physician 1 stated yes, because he was on Seroquel. b. Review of the Medication Administration Records for October, November, and December 2019 showed the orthostatic blood pressure (lying, sitting, and standing) was scheduled to be monitored every Friday during the 0700 to 1500 hours shift. However, the orthostatic blood pressure was not consistently monitored as ordered by the physician. For example, on 10/4, 10/11, 10/25, 11/1, 11/8, and 11/15/19, the blood pressure reading obtained for one position was documented for lying, sitting, and standing. On 12/4/19 at 1500 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 42's orthostatic blood pressure was being monitored related to the use of Seroquel. RN 1 reviewed the medical record and verified the orthostatic blood pressure was not monitored as ordered by the physician. 2. Medical record review for Resident 11 was initiated on 12/4/19. Resident 11 was admitted to the facility on [DATE]. Review of the Order Summary Report for the month of December, 2019 showed a physician's order dated 10/27/19, to give one capsule of Depakote 125 mg via GT at bedtime for mood lability, manifested by moaning for no reason. Another order dated 10/17/19, showed to monitor episodes of moaning for no apparent reason and document number of episodes every shift. Review of the Psychotropic Summary Sheet for October 2019 showed Resident 11 had no episodes of moaning for no apparent reason. Review of Resident 11's Medication Administration Record for October 2019 showed the resident had 9 episodes of moaning for no apparent reason between 10/28/to 10/31/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 10 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm On 12/6/19 at 0951 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 11 had nine episodes of moaning without apparent reason from 10/28 to 10/31/19, documented on the Medication Administration Record for the month of October, 2019. RN 1 verified the nurse inaccurately summarized zero episodes of moaning without apparent reason on the Psychotropic Summary Sheet. RN 1 verified the findings. Residents Affected - Few 3. Medical record review for Resident 37 was initiated on 12/4/19. Resident 37 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 37's Order Summary Report showed an order dated 10/9/19, to administer Remeron 15 mg by mouth at bed time for depression manifested by poor meal intake of less than 76%. Review of Resident 37's Medication Administration Record for the months of August and September 2019 showed Resident 37 was on Remeron 15 mg by mouth at bedtime for depression manifested by poor meal intake of less than 76%. Review of the POC Legend Report documented by the CNAs and the Medication Administration Records documented by the licensed nurses to show monitoring of poor intake of less than 76% for the months of August and September 2019 showed multiple inconsistencies. For example, the CNAs' documentation showed Resident 37 had 28 episodes of meal intake of less than 76% for the month of August 2019 and 41 episodes for the month of September 2019; however, the nurses' documentation showed zero episodes of meal intake of less than 76% for the months of August and September 2019. Review of the psychiatrist's Behavior Management Follow Up dated 10/17/19, showed Resident 37 had zero episodes of poor meal intake less than 76% for the months of August and September 2019. On 12/5/19 at 0914 hours, an interview was conducted with CNA 4. CNA 4 was asked if she removed the residents' meal trays. CNA 4 stated she removed the residents' meal trays and documented meal intake in the computer. If residents did not eat well or refused meals, then she notified the nurses. On 12/5/19 at 1228 hours, an interview was conducted with LVN 1. LVN 1 was asked if the nurses checked Resident 37's meal intake. LVN 1 stated only sometimes, but the CNAs checked the residents' meal intake all the time. LVN 1 was asked how she knew Resident 37's meal take and how she documented the meal intake. LVN 1 stated the CNAs verbally reported to the nurses when residents refused meals or meal intake was less than 25%. LVN 1 stated she documented the residents' meal intake based on the CNAs' meal intake documentation and their verbal reports. On 12/5/19 at 1220 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the CNAs' meal intake documentation and the nurses' meal intake documentation did not match. The DON stated the psychiatrist was relying on the nurses' meal intake documentation on the Medication Administration Record, which was inaccurate. The DON acknowledged and verified the above findings. 4. Medical record review for Resident 19 was initiated on 12/4/19. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report dated 12/4/19, showed a physician's order dated 10/17/19, to administer Risperdal 1 mg, give one tablet at bedtime for psychosis manifested by auditory hallucinations. Another physician's orders dated 9/29/19, showed to monitor Resident 19's orthostatic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 11 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 blood pressure in the laying, sitting, and standing positions during the day shift, every Sunday. Level of Harm - Minimal harm or potential for actual harm According to the Highlights of Prescribing Information for Risperdal from the Food and Drug Administration, Section 5.7 Warnings and Precautions showed to monitor for orthostatic vital signs. The drug could cause a decrease in blood pressure when rising too quickly from a sitting or lying position. Residents Affected - Few Review of the Weights and Vitals Summary from October 6 through November 24 2019, an orthostatic blood pressure was measured on 10/13/19 at 0743 hours, but it was only for lying and sitting, not standing. On 11/3/19 at 0931 hours, two blood pressures were taken, but both were in the sitting position, and on 11/24/19 at 0833 and 0834 hours, blood pressures were taken, but both were taken in the sitting position. There was no further documentation to demonstrate orthostatic blood pressures were attempted. On 12/4/19 at 1408 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 19 had a physicians' order for orthostatic blood pressure monitoring to be taken every Sunday. LVN 3 stated Resident 19 was capable of standing up with assistance. LVN 3 verified no orthostatic blood pressures had been taken for Resident 19 and should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 12 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure one of 18 final sampled residents (Resident 65) and 15 nonsampled residents (Residents 16, 24, 28, 31, 32, 52, 53, 56, 59, 61, 64, 66, 68, 69, and 74) physicians' orders for diets were followed. The facility failed to prepare the portion sizes in advance on the menu for four residents. * Facility failed to follow the menu items for Residents 16, 24, 28, 31, 32, 52, 53, 56, 59, 61, 64, 65, 66, 68, 69, and 74 who had physicians' orders for NCS (no concentrated sweets) diets. * Facility failed to prepare the portion sizes in advance on the menu for three residents who had physicians' orders for large portion meals and one resident who had a physician's order for small portion meals. These posed the risk of the residents' nutritional needs not being met. Findings: 1a. On 12/4/19 at 0820 hours, Resident 74 was observed for breakfast in her room. Review of Resident 74's meal ticket showed Resident 74 was on a NCS diet. Resident 74 was observed with a slice of orange on her tray. On 12/4/19 at 0823 hours, an interview was conducted with the DSS. The DSS verified the above findings and stated Resident 74 should not have been served the orange. b. Medical record review for Resident 44 was initiated on 12/4/19. Resident 44 was admitted to the facility on [DATE]. Review of Resident 44's Order Summary Report dated 12/4/19, showed a physician's order dated 11/18/19, for a NAS (no added salt), NCS diet. On 12/4/19 at 0824 hours, Resident 44 was observed for breakfast in his room. Review of Resident 44's meal ticket showed Resident 44 was on a NCS diet. Resident 44 was observed with a slice of orange on his tray. During a concurrent interview, the DSS verified the above findings and stated Resident 44 should not have been served the orange. c. On 12/5/19 at 1147 hours, an observation of the kitchen tray line was conducted. The menu extension spreadsheet failed to include portion serving sizes for residents with small and large portion sizes ordered. One scoop was observed to be in each container on the tray line. [NAME] 1 stated everyone got the same amount of food. [NAME] 1 stated no residents were to receive small portion sizes. A concurrent interview was conducted with the DSS. The DSS stated the facility had no residents who were to receive small or large portion sizes. On 12/5/19 at 1254 hours, an interview and document review was conducted with the RD and DSS. The RD verified the serving sizes for small and large portions were not found on the menu extension spreadsheet. The facility document titled Roster by Name dated 12/5/19, showed two residents were to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 13 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some receive large portion sizes, one resident was to receive a double size diet, and one resident was to receive a small portion size diet. The DSS verified the above findings and stated the double portion size was an error and should have showed a large portion size. The DSS verified The RD was asked how the kitchen staff would know what serving scoop size to use when platting food for residents who were to receive small or large portion sizes. The RD stated the facility used to have a paper on the wall which showed the staff what serving scoop to use for small and large portion sizes, but it was no longer posted. The RD verified she was unable to locate the paper. 3. On 12/4/19 at 0805 hours, breakfast observation was conducted in the residents' rooms. Review of the meal tickets Residents 24, 56, 66, and 68 showed they were supposed to receive an NCS diet. Review of the facility's breakfast menu for Week 3, Wednesday, for the NCS diet showed the residents were not supposed to get any fruit. However, During the breakfast meal observation, Residents 24, and 66 received fresh mixed fruit, Resident 68 received fruit cocktail in syrup; and Resident 56 received pureed fruit cocktail. On 12/4/19 at 0815 hours, the DSS acknowledged the residents on NCS diets were not supposed to receive any fruit according to the menu. The DSS verified the findings. 2. On 12/4/19 at 0727 hours, breakfast observation was conducted in the facility's only dining room. Review of Residents 16, 28, 31, 32, 52, 53, 59, 61, 64, 65, 69, and 74's meal tickets showed they were supposed to receive an NCS diet. Review of the facility's breakfast menu for Week 3, Wednesday, for NCS diet the residents were not supposed to get any fruits. However, observation of the meal trays for Residents 16, 28, 31, 32, 52, 61, 64, 65, and 74 showed they received fruit cocktail in syrup. Residents 53, 59, and 69 received pureed fruit cocktails. On 12/4/19 at 0751 hours, the DSS was called and verified the residents on NCS diets were not supposed to receive any fruit according to the menu. The DSS stated the cook made a mistake and included fruit on the breakfast trays for NCS diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 14 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 - Potential for minimal harm Based on observation, interview, and facility document review, the facility failed to ensure the nutritive value of the pureed Beef Soup W/PA & Tomato was conserved when the pureed Beef Soup W/PA & Tomato was prepared more than two hours prior to meal service and held in the oven. This failure placed 21 residents receiving a pureed diet at risk for compromised nutritional status. Residents Affected - Some Findings: On 12/5/19 at 1015 hours, a request was made to [NAME] 2 to observe the preparation of the pureed Beef Soup W/PA & Tomato. [NAME] 2 stated the puree had already been made and was ready to go. [NAME] 2 stated she started making the soup around 0800 hours, it was done about 0900 hours, and then pureed. On 12/5/19 at 1059 hours, an interview was conducted with the RD. The RD was asked if it was okay to hold pureed food items for two hours prior to meal service in a heated oven. The RD stated she expected the pureed foods should be cooked no longer than about an hour before being served to maintain taste, color, and nutrient density. Review of the Resident Diet Count sheet showed there were 21 residents receiving pureed diets. According to nutrition.gov (a dietary online resource), the nutritional value of food, in particular, vegetables which are heated multiple times compromises both the palatability and nutritional value of the food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 15 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store food in accordance with professional standards for food service safety. * The facility failed to ensure the proper storage of employees' food in the kitchen. This posed the potential for the residents to be exposed to harmful pathogens. * The facility failed to ensure the kitchen equipment and utensils were clean and maintained in good repair. This posed the potential of exposing the residents to harmful pathogens. * The facility failed to ensure the chemical products and supplies were clearly marked as such and stored separately from food items. This posed the potential for cleaning the products to inadvertently contaminate the food items and cause illnesses. Findings: Review of the CMS 672 Resident Census and Conditions of Residents form completed by the DON on 12/3/19, showed 67 of the 84 residents in the facility received food prepared in the dietary department. 1. On 12/3/19 at 1242 hours, a concurrent interview and observation was conducted with the DSS. Observation of the walk-in refrigerator with DSS and showed five drink items were unlabeled: Frappuccino, Muscle milk, and three cans of Rock Star. The DSS stated they were his personal drinks. Two bottles of Perrier water and an [NAME] were not labeled. The DSS stated he did not know who they belonged to. Condiments, such as barbecue sauce (unlabeled) and a can of coke were observed in the freezer. 2. Review of the facility's P&P titled Sanitization revised October 2008 showed all utensils shall be kept clean, maintained in good repair and shall be free from breaks, corrosions and chipped areas which may affect their use or proper cleaning. On 12/3/19 at 1315 hours, a concurrent observation and interview with the DSS in the dry storage showed the rusty cutlery in a plastic bag. There was rust on the knives and rust in the bag itself. The DSS stated he did not know why they were there. 3. Review of the facility's P&P titled Food Receiving and Storage revised October 2017 showed the toxic substances should not be stored in the kitchen area. The policy also showed cleaning compounds will be stored separately from food storage and labeled clearly. On 12/6/19 at 0940 hours, a red bucket filled with sanitizing fluid and a washcloth was observed on the same tray next to tea bags, masking tape, and styrofoam cups. The DSS verified the red bucket contained cleaning solution and should not have been placed next to food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 16 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure a designated IDT member coordinated care between the facility and the hospice agency for two final sampled residents (Residents 18 and 63). This failure had the potential to put the residents on hospice services at risk of uncoordinated care between the facility and the hospice agency. Findings: 1. Review of the hospice contract dated 5/21/13, between the hospice agency caring for Resident 18 and the facility failed to show who the designated facility IDT member was to coordinate the services with the hospice agency. Medical record review for Resident 18 was initiated on 12/3/19. Resident 18 was admitted to the facility on [DATE]. Resident 18 was admitted to Hospice A on 12/20/18. Review of Resident 18's medical record failed to show the facility's designated staff who was to coordinate care with the Hospice A representative. On 12/4/19 at 1008 hours, an interview was conducted with CNA 2. CNA 2 stated the hospice CNAs came on shower days, Tuesday and Thursday, and the facility's IDT member designated to coordinate care with the hospice agency was the charge nurse. On 12/4/19 at 1058 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was asked who was the facility's designated IDT member to coordinate services with the hospice agency. The SSD stated she was assigned as the facility's coordinator for a few months recently. When asked to show this information in the contract with the hospice agency, the SSD was unable to show documentation she was the designated person to coordinate care with the hospice representative. The SSD stated it should be in the contract between the facility and the hospice agency. On 12/4/19 at 1125 hours, an interview and concurrent the facility document review was conducted with the DON. The DON verified the hospice agreement did not identify an IDT member responsible for coordinating care with the hospice agency. 2. Medical record review for Resident 63 was initiated on 12/3/19. Resident 63 was admitted to the facility on [DATE]. Review of Resident 63's Order Summary Report showed an order dated 11/22/19, to admit Resident 63 to Hospice A under routine level of care. Review of the Skilled Nursing Facility Service Agreement (the agreement between the facility and Resident 63's hospice agency) failed to show the designated person in the facility responsible to coordinate hospice care for Resident 63 with the hospice agency. On 12/4/19 at 1620 hours, an interview was conducted with LVN 4. LVN 4 was asked if she knew who the designated facility staff person was to coordinate hospice care for Resident 63. LVN 4 stated she was not sure. LVN 4 was asked who she discussed concerns with regarding hospice care. LVN 4 stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 17 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 0849 if there was any concern regarding hospice care, she notified the RN supervisor who was on duty. Level of Harm - Minimal harm or potential for actual harm On 12/4/19 at 1649 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator verified Hospice A's contract did not identify the designated IDT coordinator responsible for coordinating services between the hospice agency and the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 18 of 19 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and facility record review, the facility failed to implement an Antibiotic Stewardship Program to reduce the risk of unnecessary or inappropriate antibiotic use. The facility failed to ensure the use of antibiotics for residents whose symptoms did not meet McGeer's Criteria were addressed in the Infection Control Committee meetings. As a result, there were no action plans developed to address the inappropriate use of antibiotics in the facility. Residents Affected - Few Findings: According to the CDC (Centers for Disease Control and Prevention), unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria. Review of the facility's P&P titled Antibiotic Stewardship Program (ASP) dated 9/2016 showed this policy is aimed at limiting antibiotic resistance in the post acute care setting, improving treatment efficacy and resident safety, and reducing treatment-related costs. The IP will collect and analyze infection surveillance data and monitor the adherence to the program as well as a separate report for the number of residents on antibiotics not meeting the criteria for active infection and suggest appropriate overall changes to make it a successful, well rounded program. On 12/5/19 at 1034 hours, an interview and concurrent review of the facility's infection control program was conducted with the IP and the DSD. The IP stated she was responsible for the facility's Infection Control and Antibiotic Stewardship Programs. The IP stated the facility utilized the McGeer's Criteria to define infection surveillance activities. The IP stated infection control related concerns were discussed during the Quality Assurance (QA) meeting and there was no separate ASP meetings conducted to discuss appropriate antibiotic use. Review of the Infection Control Report presented monthly to the QA meetings from January 2019 to October 2019 showed high incidents of antibiotic use in residents whose symptoms did not meet the McGeer's Criteria. The report failed to show an action plan was developed to address the inappropriate use of antibiotics in the facility. For example, the number of incidents of antibiotic use for residents whose symptoms did not meet the McGeer's Criteria increased from four in March 2019 to 12 in April 2019; and from five in August 2019 to 15 in September 2019 (300% increase from the previous month). The IP and the DSD verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 19 of 19