Health inspection·March 23, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm On 03/22/23 at 1154 hours, an interview was conducted with LVN 2. When asked about the policy about informed consent, LVN 2 stated the informed consent was needed for the psychotropic medications. LVN 2 further explained the informed consent included the risk and benefits of the treatment to the resident or responsible party. Residents Affected - Few On 03/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 2 of 21 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 03/23/2023 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to accommodate the individual needs and preferences for two of 20 final sampled residents (Residents 36 and 72) when the call lights button were placed out of the residents' reach. This failure could delay in providing the residents assistance to meet their needs. Residents Affected - Few Findings: Review of the facility's P&P titled Call Light Answering dated 3/2010 showed to place the call device within the resident's reach before leaving the room and if the call light/bell is defective, immediately report this information to the unit supervisor. 1. Resident 72 was admitted to the facility on [DATE], with diagnoses including S/P right leg below knee amputation, DM, PVD, and general weakness. Review of Resident 72's MDS dated [DATE], showed Resident 72 had a BIMS Score of 14 (cognitively intact), needed extensive assistance from staff for bed mobility and transfers, and had ROM impairment on one side of lower extremity. On 03/20/23 at 1545 hours, an observation and concurrent interview was conducted. The call light and TV control were under Resident 72's pillow on the left side of the bed. Resident 72 was asked to reach for the call light and stated, I don't see where my call light. CNA 6 acknowledged the resident could not reach the call light that was placed under the resident's pillow and stated, I will move it closer to the resident. CNA 6 verified the call light should always be within the resident's reach. On 03/20/23 at 1548 hours, during an observation and concurrent interview with LVN 3, Resident 72's call light and TV control were under the resident's pillow on the left side of bed. LVN 3 stated, resident is s/p fall, has right below knee amputation and risk for fall. LVN 3 acknowledged the resident's call light and TV control were under the resident 's pillow out of resident's reach. LVN 3 verified the call light should always be within resident's reach. 2. During a concurrent observation of Resident 36's room and interview with LVN 2 on 3/20/23 at 0908 hours, Resident 36's call light was observed not within resident's reach. Resident 36 was observed sitting up in the wheelchair by the foot of the bed while the call light was located at the head of the bed. LVN 2 verified the call light was not within the resident's reach and stated the resident should have been sitting closer to the call light. LVN 2 acknowledged the importance of keeping the call light within reach was for safety purposes and to help the residents with their needs. During a subsequent observation on 3/21/23 at 1343 hours, Resident 36 was observed sitting up in wheelchair at the foot part of the bed with the call light attached at the head of the bed. During a concurrent interview with RN 2, she verified the call light was not within reach. RN 2 stated the facility protocol was to keep the call lights within reach as it was a form of communication to the staff for when they needed assistance. Review of Resident 36's medical record was initiated on 3/22/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 3 of 21 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 03/23/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Review of Resident 36's nurse's notes dated 2/2/23 at 2330 hours, and 2/3/23 at 1842 hours, showed the call light was at reach all time. Further review of Resident 36's plan of care showed the care plan problems addressing the resident's incontinence of bladder and high risk for falls and injury which included the intervention for call light to be within the resident's reach. Residents Affected - Few On 3/23/23 at 1630 hours, the DON was informed of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 4 of 21 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 03/23/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDS assessments were accurately completed for two of 20 final sampled residents (Residents 5 and 91). This posed the risk of the residents not receiving an individualized plan of care based on the residents' specific needs. Residents Affected - Some Findings: Review of the facility's P&P Resident Assessment Instrument revised 4/2021 showed the MDS Coordinator will ensure information is accurately entered into a resident's database. 1. Medical record review for Resident 91 was initiated on 3/20/23. Resident 91 was originally admitted to the facility on [DATE]. Resident 91 was transferred to the acute care hospital on [DATE], and readmitted on [DATE]. The medical record also showed Resident 1 was discharged to home on 1/7/23. On 3/22/23 at 1118 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator was asked when Resident 91 was discharged from the facility. The MDS Coordinator stated Resident 91 was discharged to home on 1/7/23. Reviewed of the MDS dated [DATE], Section A for Discharge Status showed Resident 91 was coded for discharged to an acute care hospital instead of discharged to home. The MDS Coordinator stated Resident 91's MDS was coded in error. The MDS Coordinator stated LVN 5 was the one who completed Resident 91's MDS Section A (Discharge Status). The MDS Coordinator verified Resident 91's MDS dated [DATE], was coded inaccurately for the resident's discharge status. On 3/22/23 at 1123 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was asked when Resident 91 was discharged from the facility. LVN 5 stated Resident 91 was discharged to home on 1/7/23. LVN 5 verified Resident 91's MDS was coded inaccurately under Section A. On 03/22/23 at 1135 hours, an interview and concurrent medical record review conducted with DON. The DON acknowledged the findings. 2. Medical record review for Resident 5 was initiated on 03/20/23. Resident 5 was admitted to the facility on [DATE], with the diagnosis of chronic kidney disease and dementia. Review of Resident 5's admission MDS dated [DATE], showed the following: - Section Q - Resident 5 had no guardian or legally authorized representative - Section S - the Physician Orders for Life-Sustaining Treatment (POLST) was signed by the resident or legally recognized decision maker Review of the POLST signed on 2/12/23, showed a signature of Resident 5's legally recognized decisionmaker who was Resident 5's family member. Review of the form Appointment of Representative signed 2/16/23, showed the appointed representative for Resident 5 was Resident 5's family member. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 5 of 21 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 03/23/2023 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 0641 Level of Harm - Potential for minimal harm On 03/22/23 at 0835 hours, an interview and concurrent medical record review was conducted with the MDS Director. When asked about Resident 5's legal decision maker, the MDS Director stated Resident 5's daughter was the appointed legal decision maker. Upon review of the MDS Sections Q and S, the MDS Director verified the information documented in Section Q regarding Resident 5 had no legal decision maker was incorrect. She further stated Section Q was completed by the social services department. Residents Affected - Some On 03/22/23 at 1027 hours, an interview and concurrent medical record review was conducted with the Director of Social Services. When asked about Resident 5's legal decision maker, the Director of Social Services stated Resident 5's family member was the legal decision maker. When asked if she completed Section Q of the MDS, she stated yes. Upon review of the MDS Sections Q and S, the Director of Social Services verified there was a discrepancy regarding Resident 5's legal decision maker. On 03/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 6 of 21 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 03/23/2023 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 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 interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 5)'s care plan was developed to be comprehensive and person-centered to address Resident 5's psychotropic medication use. This failure had the potential to cause unnecessary use of mirtazapine and quetiapine for Resident 5. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Center revised December 2016 showed a comprehensive, person-centered care plan should be developed and implemented for each resident. Medical record review for Resident 5 was initiated on 3/20/23. Resident 5 was admitted to the facility on [DATE], with diagnosis of dementia. Review of Resident 5's Order Summary Report for the month of March 2023 showed the following: - an order started on 2/13/23, for mirtazapine tablet 7.5 mg at bedtime for depression manifested by poor food intake. - an order started on 2/13/23 for quetiapine tablet 25 mg at bedtime for psychosis manifested by auditory hallucinations as evidenced by frequent talking to self. Review of Resident 5's Care Plan with the initiation date of 2/13/13, showed the non-drug interventions prior to the use of mirtazapine and quetipine were as follows: - The non drug intervention prior to the use of psychotropic (a drug that affects a person's mental state) medication (mirtazapine) included to check for presence of pain, change position for comfort, offer snacks, turn on TV to show program of choice, listen to music of choice, and provide reading material and magazine. - The non drug intervention prior to the use of psychotropic medication (quetiapine) included to check for presence of pain 2, change position for comfort. offer snacks, turn on TV to show program of choice, listen to music of choice, and provide reading material and magazine. On 3/22/23 at 1154 hours, an interview was conducted with LVN 2. When asked what the use of resident care plans was, LVN 2 stated the nurses looked at the care plans for guidance on the resident's care. LVN 2 explained the care plan should be specific to the resident's issue. On 3/22/23 at 1427 hours, an interview and concurrent medical review was conducted with RN 1. When asked what the facility's policy was on the care plans, RN 1 stated the care plans should be specific to the resident's condition. Upon review of Resident 5's care plans for non-drug interventions prior to the use of mirtazapine and quetiapine, RN 1 verified the interventions listed on Resident 5's care plan were not personalized for the order indications of mirtazapine and quetiapine. On 03/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 7 of 21 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 03/23/2023 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 ensure one of six nonsampled residents (Resident 4) was provided accurate doses of prescribed vitamin C (supplement). This failure had the potential to cause harm to Resident 4. Findings: Review of the facility's P&P titled Administering Medications revised December 2012 showed the dosage of a medication must be recorded in the resident's medical record. Medical record review for Resident 4 was initiated on 3/20/22. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis including pressure induced deep tissue damage to the left and right heels. On 3/21/23 at 0753 hours, during the medication observation, LVN 2 prepared one tablet of vitamin C 500 mg tablet to Resident 4. Review of Resident 4's Order Summary Report for the month of March 2023 showed an order started on 3/10/23, for vitamin C oral tablet (Ascorbic Acid) one tablet by mouth two times a day for supplement. Review of Resident 4's MAR for the month of March 2023 showed Resident 4 had received vitamin C everyday since 3/10/23. On 3/21/23 at 1358 hours, an interview and concurrent medical review was conducted with LVN 2. When asked to describe the process of administering the medications, LVN 2 stated he checked for the right patient, right time, right medication, right dosage, and right route of administration. When asked what he would do if he came across a medication order that did not state the medication dose, LVN 2 stated the process would be to notify the ordering provider to ask for the medication dose. Review of Resident 4's medical record, LVN 2 verified the ordered vitamin C did not state the medication dose. LVN 2 further stated Resident 4's vitamin C should have a dose; otherwise, the nurses would not know how much vitamin C to administer. LVN 2 stated the facility had vitamin C 500 mg/tablet and a 250 mg/tablet in stock. On 3/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 8 of 21 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 03/23/2023 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 interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 5) was provided the comprehensive assessment and management for the use of psychotropic medications. * The facility failed to ensure the physician's assessment and diagnose of Resident 5 were completed and documented for the use of mirtazapine and quetiapine. * The facility failed to document the non-pharmacological interventions attempted prior to the administration of mirtazapine and quetiapine for Resident 5. These failures had the potential to cause harm to Resident 5. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated October 2017 showed the facility should ensure that a physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacological medication is necessary. Medical record review for Resident 5 was initiated on 3/20/23. Resident 5 was admitted to the facility on [DATE], with diagnosis of chronic kidney disease and dementia. Review of Resident 5's Order Summary Report for the month of March 2023 showed the following: - an order dated on 2/13/23 for mirtazapine Tablet 7.5 mg at bedtime for depression manifested by poor food intake. - an order dated on 2/13/23, for quetiapine Tablet 25 mg at bedtime for psychosis manifested by auditory hallucinations as evidenced by frequent talking to self. 1. Review of Resident 5's History and Physical Examination dated 2/14/23, did not show documentation Resident 5 had depression manifested by poor food intake, or psychosis manifested by auditory hallucinations as evidenced by frequent talking to self. Review of Resident 5's admission MDS dated [DATE], showed the following: - Section D: Resident 5 had no symptom of poor appetite or overeating. - Section E: Resident 5 had no potential indicators of psychosis, such as hallucinations or delusions. On 03/22/23 at 0903 hours, an interview and concurrent medical review was conducted with RN 1. When asked to provide documentation of the physician's assessment for the use of psychotropic medications, mirtazapine and quetiapine, RN 1 verified the physician's assessment and diagnosis were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 9 of 21 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 03/23/2023 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 documented. Level of Harm - Minimal harm or potential for actual harm On 03/23/23 at 1406 hours, an interview with the facility's Medical Director was conducted. When asked about the process of psychotropic medication use, the Medical Directed stated the physician's assessment should be completed prior to ordering psychotropic medications. Residents Affected - Few 2. Review of Resident 5's Order Summary Report for the month of March 2023 showed the non drug intervention orders for mirtazapine and quetiapine were the same as follows: - Check for presence of pain - Change position for comfort - Offer snacks - Turn on TV to show program of choice - Listening to music of choice - Provide reading material and magazine Review of the Medication Administration Record (MAR) for the month of February and March 2023 showed that Resident 5 had received mirtazapine and quetiapine everyday since admission. There were no documented evidence of the attempted non drug interventions prior to administer the mirtazapine and quetiapine medications. On 3/22/23 at 1154 hours, an interview was conducted with LVN 2. When asked about the process of administering psychotropic medications, LVN 2 stated the nurses should attempt non-pharmacological interventions prior to administering a psychotropic medication. On 3/22/23 at 1427 hours, a concurrent interview and medical record review was conducted with RN 1. When ask about the policy on psychotropic medications, RN 1 stated the non-pharmacological interventions should be completed prior to administering psychotropic medications. RN 1 further stated the non-pharmacological interventions should be charted whenever it was performed. Upon review of Resident 5's MAR, RN 1 verified the non-pharmacological interventions for mirtazapine and quetiapine were not documented. On 3/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 10 of 21 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 03/23/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. 3. On 3/20/23 at 1100 hour, during an obervation with RN 1, the following medications were found unattended and unlocked in the right bottom drawer of the Nurse's Station: - Two opened bottle of Tenofovir disoproxil fumarate (antiviral) tablets 300 mg with the expiration dates of 3/24 and 8/24, respectively. - Two opened bottle of artificial tears, Gericare eye drops 15 ml - Four unopened pouch of Ipratropium Bromide (bronchodilator) 0.5 mg and albuterol sulfate (bronchodilator) 3 mg inhalation solution 2.5 mg with the expiration date of 9/24 - Seven vials of Formoterol fumarate inhalation solution (use to reduce wheezing, coughing, and shortness of breath) 20 mcg/2 ml with the expiration date of 11/24 - One opened bottle of promethazine-DM (for cough) 6.25 -15 mg/5 ml 2 teaspoonful/10 ml by mouth 3 times daily for cough, to discontinue on 2/23/23, for 14 days only, with 50 ml remaining - Two unopened Budesonide inhalation suspension (corticosteroid, works by decreasing inflammation of the airways) 0.25 mg/2 ml unit dose with the expiration date of 7/24 - One opened bottle of Megestrol acetate (a progestin medication which is used mainly as an appetite stimulant) 40 mg per ml with the opend date of 11/15/22, and expiration date of 7/25 - Six skin protectant vitamin A and D periguard ointment Dermarite petroleum - One unopened Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg per 3 ml for 30 vials - One opened, unlabeled liquid medicine bottle, 200 ml - One opened bottle of Calcitonin salmon nasal spray (osteoporosis) 20 ml for osteoporosis with the expiration date of 11/24 - One opened of Albuterol sulfate Hfa inhalation with 172 dose remaining - One opened bottle of Gaviscon Liquid Antacid Extra Strength with the expiration date of 9/24 - Four unopened Lovenox (anticoagulant) 40 mg/0.4 ml syringe with the expiration date of 10/24 - Four unopened Lovenox 40 mg/0.4 ml syringe with the expiration date of 9/24 - One unopened and unlabled tube of Diclofenac Sodium Topical Gel (relieve joint pain) 1% with the expiration date of 11/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 11 of 21 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 03/23/2023 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 0761 - One unopened bottle of Sevelamer (used to control high blood levels of phosphorus in people with chronic kidney disease) 800 mg tablet with the expiration date of 7/25 Level of Harm - Minimal harm or potential for actual harm - One opened bottle of Megestrol 40 mg/ml with the opened date of 2/8/23, and expiration date of 10/25 Residents Affected - Many - One opened bottle of Megestrol 40 mg/ml with the opened date of 1/26/23, and expiration date of 10/25 - One unopened bottle of Megestrol 40 mg/ml with the expiration date of 11/25. - One opened Advair HFA (bronchodilator) 230 mcg/21 mcg (no resident's name) with the opened date of 11/25/22 - Four rectal suppository Bisacodyl (laxative) 10 mg with the expiration date of 5/24 - One unopened box of Gericare Artificial Tears with the expiration date of 10/24 The above medications were stored with the nursing drug book, stethoscope, dry vermicelli, instant coffee, tea bag, four pieces of chocolate, the lettuce in the bottom left corner, two syringe, used goggle, knife and drug sticker label. RN 2 was asked to lift the medications and the bottom of drawer surface was observed to be sticky and dirty from debris and food particle. RN 2 verified the findings. On 3/20/23 at 1135 hours, an interview and concurrent record review was conducted with RN 2. RN 2 was asked about all the above medications that were stored in the nursing station drawer in Station 1. RN 2 stated she did not know why all those medications were there. RN 2 stated those medications had been discontinued or belonged to the discharged residents. She would put the medications for disposal in the medication room. Normally, the over counter mediciations were locked in the medication room. Two nurses would need to dispose medication, signed off, filled out form with name of the medication, date, how many medications were remaining, name of the resident, and direction of the medication. Medications must be stored in the medication room and medication cart. RN 2 was asked about Tenofovir disoproxil fumarate, RN 2 stated it was for hepatitis medicine and the resident had been discharged . RN 2 was asked about the syringes; RN 2 stated it was for Dilantin use. RN 2 verified the above findings. 4. On 3/20/23 at 1503 hours, during the medication storage observation with RN 2, the treatment cart was found with the following supplies: - three Lemon Glycerin Swab Sticks with the expiration date of 10/15/21 - one Calcium Alginate Wound Dressing was opened and used. The packaging showed it was a sterile product. - one Transparent Film Wound Dressing with label and grid was opened and used. The packaging showed it was a sterile product. On 3/20/23 at 1551 hours, and interview was conducted with RN 2. Upon review of the above items, RN 2 stated the expired Lemon Glycerin Swab Sticks, the opened and used Calcium Alginate Wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 12 of 21 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 03/23/2023 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 0761 Dressing, and the opened and used Transparent Film Wound Dressing should not be in the treatment cart. Level of Harm - Minimal harm or potential for actual harm On 3/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. Residents Affected - Many Based on observation, interview, and facility P&P review, the facility failed to ensure the proper administration, storage, and disposal of the medications in a safe manner as evidenced by the following: * The facility failed to ensure the medications were not left unattended. * The facility failed to ensure the discontinued medications were properly stored and disposed. * The facility failed to ensure the expired lemon glycerin swab sticks and used sterile wound dressing supplies were disposed from the treatment cart. These failures had the potential to cause unsafe handling and storage of the residents' medications. Findings: 1. Review of the facility's P&P titled Storage of Medications revised April 2007 showed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation of Resident 58's room on 3/20/23 at 0845 hours, one medication cup containing seven medications observed unattended at Resident 58's bedside. During a concurrent interview with Resident 58, the resident was unable to state what the medications were in the medication cup. On 3/20/23 at 0850 hours, LVN 2 returned to Resident 58's room. During an interview with LVN 2 in Resident 58's room, LVN 2 verified seven medications were left unattended at Resident 58's bedside and included the following: - Two vitamin D tablets (supplement), - One colace softgel (stool softener), - One multivitamin with mineral tablet (supplement), - One Zyertc tablet (allergy medication), and - Two Tylenol tablets (pain medication) LVN 2 stated he did not mean to leave the medications unattended at the bedside but did when he went to check on the resident next door. LVN 2 also stated he informed the residents what medications they were taking. LVN 2 acknowledged the facility's protocol was to stay with the resident when taking their medications from beginning to end and further stated it was important to not leave the medications unattended for safety reasons, to ensure someone else did not take them and the residents took all the prescribed medications as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 13 of 21 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 03/23/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with RN 2 on 3/21/23 at 1348 hours, RN 2 stated the facility's protocol was to make sure the residents took the prescribed medications and not to leave medications unattended at bedside. RN 2 further stated somebody else could take the medication when it was not prescribed to them. 2. Review of the facility's P&P titled Storage of Medications revised April 2007 showed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 3/20/23 at 1057 hours, during a concurrent observation and interview with RN 2 of the medication storage, under the table of Nurse's Station One, there was an unlocked isolation cart labeled Medical Records with medications. RN 2 verified the following medications were included: - One opened bottle of ferrous gluconate (iron supplement) with the expiration date of 3/24, - One opened bottle of zinc (supplement) with the expiration date of 4/23, - One opened bottle of oyster shell calcium plus vitamin D (supplement) with the expiration date of 4/24, - One opened bottle of aspirin (nonsteroidal anti-inflammatory) with the expiration date of 5/24, - Two 10 ml syringes of normal saline for IV flushes with the expiration dates of 4/25 and 10/25, - Another two 10 ml syringes of normal saline for IV flushes were also found behind the computer at Nurse's Station One with the expiration dates of 10/25 and 11/25, - One opened box of enema (stool management) with the expiration date of 6/23, - One box contained both oral medication and rectal suppository, including one opened bottle of vitamin C (supplement) with the expiration date of 11/24 and rectal bisacodyl (suppository stool softener) with the expiration date of 6/24, and - Two bubble packets with no name, unlabeled with no pharmacy paperwork to identify the medications. One bubble packet included 30 yellow capsules and another bubble packet with seven yellow capsules. Both bubble packets had Gabapentin handwritten on the packets. RN 2 verified she was unsure if the capsules in the bubble packet were Gabapentin since there was no pharmacy label on the bubble packets. RN 2 also verified the medications found at Nurse's Station One did not include the date when they were opened on any of the opened bottles and were not securely locked. On 3/20/23 at 1135 hours, an interview with RN 2 was conducted. RN 2 stated the over-the-counter medications and other medications were locked in the medication room and not to be kept at the nurse's station. RN 2 verified the process of medication disposal was to dispose as needed and included two nurses to dispose and sign off. RN 2 further emphasized the medications must be securely locked in the medication room. On 3/20/23 at 1146 hours, during a concurrent observation of medication found under the table at Nurse's Station Two and interview with RN 1, unsecured and opened medication was observed. RN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 14 of 21 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 03/23/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many verified one opened bottle of normal saline with the expiration date of 6/2024 was found in the drawer at Nurse's Station Two. RN 1 stated the medication should not be at the nurse's station and removed the medication. On 3/20/23 at 1150 hours, during a concurrent observation of the Charting Station across from Nurse's Station Two and interview with RN 1, unsecured medication was found in an unlocked isolation cart under the table. RN 1 verified the medication found was DermaFungal Antifungal Cream with 2% miconazole with the expiration date of 1/24. RN 1 acknowledged the medications must be placed for medication disposal, and removed medication from the isolation cart. On 3/23/23 at 1417 hours, an interview with the Pharmacy Consultant was conducted. The Pharmacy Consultant stated the expectation for medication disposal was to keep the discontinued medications quarantined in a location in the medication room or locked cabinet drawer in the medication room. The Pharmacy Consultant stated there was a time frame to destroy or get rid of the medications and medication disposal should be in a safe, designated, and located in a place that is controlled by the licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 15 of 21 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 03/23/2023 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. Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the puree recipes were followed during the puree food preparation for 18 of 96 residents who received puree diets. This failure posed the risk for the inconsistent puree product which could alter the quality and nutrient content of the puree food for the residents receiving puree diets. Findings: Review of the facility's P&P titled Food Preparation dated 2018 showed the facility should prepared food by methods that conserve nutritive values, flavor and appearance. The facility will use approved recipes, standardized to meet the residents needs. The recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 1. Review of the Stir Fry Vegetables, Puree dated 5/29/19, showed the ingredients for puree vegetables were as follows: five slices of wheat bread and four tablespoons of Margarine for ten portions. Instructions for puree vegetables included to add the margarine and bread while processing and process until smooth. On 3/22/23 at 1023 hours, during the pureed food preparations, a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing 18 servings portions of cooked vegetables for lunch meal. [NAME] 1 placed nine serving portions of cooked vegetables in the food processor, added chicken broth and two slices of bread, and checked the pureed vegetables for consistency. [NAME] 1 placed another nine serving of cooked vegetables in the food processor, added chicken broth and two slices of bread, and checked the pureed vegetables for consistency. [NAME] 1 added a total of four slices of bread for the 18 servings of pureed vegetables. [NAME] 1 placed the pureed vegetables in a saucepan and covered with a thin foil. [NAME] 1 was observed not adding margarine to the pureed vegetable. 2. Review of the Steam Rice, Puree dated 5/29/19, showed the ingredients for puree rice were as follows: half quart of chicken broth and two tablespoons of Margarine for ten portions. Instructions for puree included to gradually add hot broth and melted margarine while processing. On 3/22/23 at 1030 hours, during the pureed food preparation, a concurrent observation and interview with [NAME] 1 was conducted. [NAME] 1 stated he was preparing 18 serving portions of pureed rice for lunch meal. [NAME] 1 placed nine serving portion of cooked rice to food processor, added water, and checked for consistency. [NAME] 1 placed the pureed rice in a saucepan and covered with a thin foil. [NAME] 1 placed another nine servings of cooked rice in the food processor, added water, and checked for consistency. [NAME] 1 added water instead of chicken broth to the pureed rice and did not add margarine as per the recipe. On 3/22/23 at 1402 hours, a concurrent interview and facility document review was conducted with [NAME] 1. [NAME] 1 was informed of the above findings. [NAME] 1 stated he could adjust the ingredients based on the consistency of the pureed foods. [NAME] 1 was asked if the adjusting of ingredients for the pureed food was part of the instructions on pureeing foods. [NAME] 1 reviewed the puree recipe and was not able to show the instructions. [NAME] 1 verified he did not add margarine to the pureed food and added water instead of chicken broth to the pureed steam rice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 16 of 21 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 03/23/2023 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 On 3/23/23 at 1430 hours, a concurrent interview and facility document review was conducted with the DSS and RD. The DSS and RD were informed of the above findings. The DSS and RD stated the approved pureed recipes should have been followed to meet the nutritional requirements for each serving portions for the residents. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 17 of 21 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 03/23/2023 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility's P&P review, and facility document review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure the cutting boards were in the sanitary conditions. * The facility failed to ensure the meat slicer was in the sanitary conditions. * The facility failed to ensure that cooked items were properly stored, labeled, and dated. * The facility failed to ensure the temperature of beverages were checked prior distributing to the residents. * The facility failed to ensure the dietary staff maintained proper handling of dirty to clean plates and utensils. * The facility failed to ensure the dietary staff maintained proper hand hygiene. These failures had the potential to cause foodborne illness to a medically vulnerable resident population who consumed food prepared in the kitchen Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/20/23, showed 85 of 96 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation dated 2018 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the USDA Food Code 2022 4-501.12, Cutting Surfaces, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. During an observation and concurrent interview with the DSS on 3/21/23 at 0855 hours, a white and green cutting board was observed heavily marred with dark discolorations knife marks. The DSS verified the finding and stated he would replace the set of the cutting boards. 2. According to the USDA Food Code 2022 4-202.11, Food-Contact Surfaces, the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. On 3/21/23 at 0855 hours, an observation of the kitchen was conducted. The metal part of meat slicer was observed with rust. The DSS verified the metal part of the meat slicer was rusty and stated it was difficult to clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 18 of 21 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 03/23/2023 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 An interview with the DSS on 3/22/23 at 1420 hours was conducted. The DSS stated he would remove the meat slicer and buy the sliced meats. On 3/22/23 at 1403 hours, review of the facility document was conducted. Review of the document titled Dietary Cleaning Schedule for Week 3/20/23 - 3/26/23 showed the cook was assigned to check the meat slicer for cleanliness on Tuesday. 3. Review of the facility's P&P titled Food Receiving and Storage dated 2018 showed other opened containers must be dated and sealed or covered during storage. According to the USDA Food Code 2022, Risk-based Inspection Methodology, foods that should be date marked and is not should be discarded. On 3/20/23 at 0807 hours, a concurrent observation and interview was conducted with the DSS. The DSS verified two sunny side up eggs and bacon were observed in the oven uncovered, unlabeled, and not dated. The DSS stated the eggs and bacon should not be kept in the oven and the staff should not store food in the oven. During an interview with the DSS on 3/22/23 at 1420 hours, the DSS stated the cooked eggs and bacon found in the oven on 3/20/23, was for the staff. 4. Review of the facility's P&P titled Sanitation dated 2018 showed thermometers will also be used to check the food at mealtimes. According to the USDA Food Code 2022, one of the epidemiological outbreak risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to food borne illness include the improper holding temperatures. On 3/22/23 at 1210 hours, a concurrent observation and interview was conducted with Dietary Aide 1 during the tray line observation. During the observation, the temperature was not checked for beverages, including milk and juices placed on food trays stored in Food Cart One. Dietary Aide 1 verified the temperatures of beverages were not checked. 5. Review of the facility's P&P titled Sanitation dated 2018 showed a minimum of two employees will be used when dishes are machine washed. One will handle the soiled area and one 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. The P&P also showed all food and nutrition service staff shall know the proper hand washing technique. According to the USDA Food Code 2022 4-702.11, Before Use After Cleaning, sanitization is accomplished after the warewashing steps of cleaning and rinsing so that utensils and food-contact surfaces are sanitized before coming in contact with food and before use. 6. According to the USDA Food Code 2022 3-301.11, Preventing Contamination from Hands, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. According to the USDA Food Code 2022 2-301.14, When to Wash, showed food employees shall clean their hands and exposed portions of their arms after engaging in other activities that contaminate the hands. In addition, according to the USDA Food Code 2022 2-301.11, Clean Condition, the hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 19 of 21 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 03/23/2023 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 fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. On 3/21/23 at 0840 hours, a concurrent observation and interview was conducted with Dietary Aide 2. Dietary Aide 2 was observed not performing hand hygiene and changing gloves between handling of the dirty to clean plates and utensils. Dietary Aide 2 verified she did not perform hand hygiene and change out gloves when handling the dirty dishes to cleaned dishes. Dietary Aide 2 stated she was the only one assigned to dishwashing and she sometimes forgot to perform hand hygiene and change out gloves. On 3/22/23 at 1130 hours during tray line observation, the [NAME] adjusted his eyeglasses with bare hands. In a subsequent observation on 3/22/23 at 1134 hours, the [NAME] was observed adjusting his eyeglasses with gloved hands. No handwashing was observed during this observation. On 3/22/23 at 1134 hours during the tray line observation, the [NAME] checked the temperatures of the cooked vegetables, including the regular vegetables, finely chopped vegetables, and stir fry vegetables with bare hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 20 of 21 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 03/23/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed before patient contact and after glove use. This failure posed the risk of spreading infectious organism to residents in the facility. Residents Affected - Few Findings: Review of the facility's P&P titled Infection Control Guidelines for All Nursing Procedures revised August 2012 showed the conditions for performing hand hygiene include before and after patient contact, before preparing and handling medications, and after removing gloves. - On 3/20/23 at 1135 hours, during the medication administration observation for Resident 29, LVN 1 was observed wearing gloves while cleaning a glucometer (a machine to measure blood sugar) and medication tray. After cleaning the glucometer and medication tray, LVN 1 removed the old gloves and immediately put on new gloves. Hand hygiene was not observed before and after removing the contaminated gloves. LVN 1 proceeded to obtain Resident 29's blood sugar finger prick. - On 3/20/23 at 1155 hours, during the medication administration observation for Resident 6, LVN 1 was observed wearing gloves while cleaning a glucometer and medication tray. After cleaning the glucometer and medication tray, LVN 1 removed the old gloves and immediately put on new gloves. Hand hygiene was not observed before and after removing the contaminated gloves. LVN 1 proceeded to obtain Resident 6's blood sugar finger prick. On 3/20/23 at 1443 hours, an interview was conducted with LVN 1. When asked about the policy on hand hygiene, LVN 1 stated the nurses should wash hands before and after using the gloves. When asked if she performed hand hygiene after cleaning the glucometer and medication tray, LVN 1 stated she did not use the hand gel after cleaning the glucometer and medication tray. LVN 1 stated the correct process would be to perform hand hygiene in between every activity. On 3/23/23 at 1600 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 21 of 21