Other·December 20, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the concurrent RECERTIFICATION and ABBREVIATED surveys to investigate COMPLAINT No. CA00661570. Representing the California Department of Public Health: Surveyor 37689, HFEN; Surveyor 37726, HFEN; Surveyor 38492, HFEN; Surveyor 39199, HFEN; Surveyor 39999, HFEN; and Surveyor 41316, HFEN. FOR COMPLAINT NO. CA00661570: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FINDINGS WERE CITED AT F725 and F755. The surveyors entered the facility on 11/7/19 at 0700 hours. The census was 172. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living CAI - community acquired infection cm - centimeter(s) CMS - Centers for Medicare & Medicaid Services CNA - Certified Nursing Assistant DON - Director of Nursing DSD - Director of Staff Development DSS - Dietary Services Supervisor F degrees - Fahrenheit degrees g/gm - gram(s) GT - gastrostomy tube (a tube inserted through the abdomen into the stomach to administer nutrients and/or medications) HAI - healthcare associated infection (an infection developed 48 hours after admission to the facility) LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 1 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE IDT - Interdisciplinary Team IP - infection preventionist iu - international unit(s) IV - intravenous (a special "needle" inserted into a vein connected to plastic tubing to administer fluids and/or medication) Licensed Nurse - Registered Nurse or Licensed Vocational Nurse McGeer's Criteria - a set of criteria used in long-term care facilities to identify if residents' symptoms meet the criteria of a true infection MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) mg/dL - milligram(s) per deciliter ml - milliliter(s) P&P - policy and procedure PICC - peripherally inserted central catheter POLST - Physician Orders for Life-Sustaining Treatment PPE - personal protective equipment (protective clothing, goggles, masks, or other garments or equipment designed to protect the wearer's body from injury or infection) QA - quality assurance RD - Registered Dietitian RNA- Restorative Nursing Assistant RT - Respiratory Therapy/Therapist SLP - Speech-Language Pathologist TB - tuberculosis (a highly contagious lung disease) UTI - urinary tract infection

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 02/06/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 2 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 34 final sampled residents (Resident 57) and three nonsampled residents (Residents 40, 90, and 449) were provided care in a manner that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 3 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE promoted dignity and respect. * The facility failed to ensure the staff responded to Resident 57's call light in a timely manner to meet the resident's care needs. As a result, Resident 57 had to remain in soiled clothing and linen for over an hour. * The facility failed to ensure the staff was not standing over Residents 40, 90, and 449 while they were assisting the residents to eat. These failures had the potential to diminish the residents' self-esteem and self-worth. Findings: 1. On 11/7/19 at 0952 hours, an interview was conducted with Resident 57. Resident 57 stated there was usually only one CNA on duty on the 11 PM to 7 AM shifts. When asked how she knew there was only one CNA on those shifts, Resident 57 stated because the staff told her that was the reason she had to wait longer for help when she called. Resident 57 stated sometimes the 3 PM to 11 PM shift only had one CNA as well. Resident 57 stated approximately two weeks ago, she had a bowel movement and was left sitting in her feces for over an hour before she was changed. Resident 57 stated having to sit in her feces for over an hour made her feel very upset and uncomfortable. When asked how she was able to keep track of how long it took the staff to respond, Resident 57 stated she had two clocks in her room and was able to give the correct date and time. Resident 57 stated she complained to the Administrator about the lack of staffing in the subacute unit and her family member had complained to the Administrator as well, but was told by the Administrator the facility had enough staffing. Resident 57 stated she just wanted to be provided the assistance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 4 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she needed and was tired of hearing excuses. Resident 57 stated she considered herself lucky because she was alert and could verbalize her needs and could complain, but stated there were many other residents in the subacute unit who could not complain. Medical record review for Resident 57 was initiated on 11/7/19. Resident 57 was admitted to the facility on 6/12/12. Review of Resident 57's plan of care showed a care plan problem dated 5/16/16, to address Resident 57 being incontinent of bowel and bladder with the potential for skin breakdown. The approaches included to check the resident every two hours for incontinence, provide incontinence care as needed, and to keep the call light within reach. A care plan problem dated 10/14/17, to address ADL deficits due to weakness, recent illness, and quadriplegia showed the approaches included to assist Resident 57 with ADL care to the extent needed and turn and reposition the resident every two hours. A care plan problem dated 10/14/17, to address Resident 57's refusal to have her call light turned off when it was answered (until she was provided assistance by the staff member she was calling for) showed the approaches included to answer the call light promptly and attend to the resident's needs. Review of the MDS dated 8/30/19, showed Resident 57 was cognitively intact and totally dependent on two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed) and toileting (including how the resident was cleaned after elimination and pad changes). Cross reference FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 5 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to F725. 2. On 11/8/19 at 0754 hours, CNA 1 was observed standing at Resident 449's bedside feeding him breakfast. On 11/8/19 at 0759 hours, an interview was conducted with CNA 1. CNA 1 stated she was standing while feeding Resident 449 because it was more comfortable for her. Medical record review for Resident 449 was initiated on 11/8/19. Resident 449 was admitted to the facility on 10/23/19. Review of Resident 449's MDS dated 10/30/19, showed Resident 449 required extensive one person physical assistance for eating. 3. On 11/7/19 at 0800 hours, during the breakfast meal observation, CNA 4 was observed feeding Resident 90 while standing over the resident. Resident 90 was sitting in the chair in her room and CNA 4 was standing next to the resident while feeding Resident 90. Medical record review for Resident 90 was initiated on 11/8/19. Resident 90 was admitted to the facility on 3/4/19. Review of Resident 90's MDS dated 9/18/19, showed Resident 90 required extensive assistance from one person for eating. 4. On 11/8/19 at 0808 hours, during the breakfast meal observation, CNA 4 was observed feeding Resident 40 while standing over the resident. Resident 40 was sitting in the chair in her room and CNA 4 was standing next to Resident 40. Medical record review for Resident 40 was initiated on 11/8/19. Resident 40 was admitted to the facility on 5/1/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 6 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 40's MDS dated 11/8/19, showed Resident 40 required extensive assistance from one person for eating. On 11/8/19 at 0830 hours, an interview was conducted with CNA 4. CNA 4 was asked the reason why she fed residents while standing to feed them. CNA 4 stated feeding residents standing was easier and more comfortable for her.

F554 SS=D Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 12/14/2019 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 34 final sampled residents (Resident 126) did not self-administer the medications without a physician's order. * Resident 126 was observed with bottles of Artic Ice analgesic gel and Icy Hot lidocaine lotion at the bedside even though there was no physician's order for Artic Ice analgesic gel and Icy Hot lidocaine lotion or an order to selfadminister the lidocaine gel. This posed the risk for harm to the resident. Findings: On 11/7/19 at 0735 hours, bottles of Artic Ice analgesic gel and Icy Hot lidocaine lotion were observed on Resident 126's bedside table during the initial tour of the facility. Resident 126 stated the Artic Ice Analgesic gel and Icy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 7 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Hot lidocaine lotion were brought in by her family and she had applied it any time she wanted to, usually at night, by herself for her leg pain. Medical record review for Resident 126 was initiated on 11/7/19. Resident 126 was admitted to the facility on 11/1/19. Review of Resident 126's MDS dated 10/8/19, showed the resident had no cognitive impairment. Review of an assessment for the SelfAdministration Assessment Form dated 11/1/19, showed Resident 126 was not a candidate for the self-administration of medications. Review of the physician's order failed to show orders for the Artic Ice Analgesic gel and Icy Hot Lidocaine lotion, or an order for selfadministration of the medications. On 11/7/19 at 0743 hours, a concurrent observation and interview was conducted with Licensed Nurse 4. Licensed Nurse 4 verified there were two bottles of analgesic gel and lidocaine lotion on the bedside table. Licensed Nurse 4 was asked if Resident 126 could use the Artic Ice Analgesic gel and Icy Hot Lidocaine lotion by herself and kept those medications in her room. Licensed Nurse 4 stated if Resident 126 self-administered the cream and kept the medication in the room, a physician's order was needed. On 11/7/19 at 0800 hours, a concurrent interview and medical record review was conducted with Licensed Nurse 4. Licensed Nurse 4 verified Resident 126 did not have a physician's order for self-administration of medication, and there was no order to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 8 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administer the Artic Ice Analgesic gel and Icy Hot Lidocaine lotion for Resident 126.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 12/14/2019 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the call light was kept within reach for one of 34 final sampled residents (Resident 45) and one nonsampled resident (Resident 136). This failure resulted in Residents 45 and 136 not being able to use the call light to call for assistance when they required it. Findings: 1. On 11/8/19 at 0726 hours, Resident 45 was observed lying in bed. Resident 45's call light was observed hanging off the left side of the bed, not within the resident's reach. On 11/8/19 at 1229 hours, Resident 45 was observed lying in bed. Resident 45's call light was observed clipped to the top upper left corner of his bed, not within the resident's reach. Resident 45 wrote on an erasable white board to find his call light and bed control. The bed control was observed tucked in between Resident 45's mattress and side rail. On 11/8/19 at 1233 hours, the IP, who was in the hallway, was asked to come to Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 9 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 45's room. The IP verified the call light and bed control were not placed within Resident 45's reach. 2. On 11/7/19 at 0758 hours, during the initial tour of the facility, Resident 136 was heard from the hallway yelling for help and for the nurse. Upon entering Resident 136's room, Resident 136 was observed lying in bed. Resident 136's call light was observed hanging off the right side of the bed, not within the resident's reach. Resident 136 stated she did not feel good and needed help from her nurse. Resident 136 also stated she soiled herself and needed to be changed. On 11/7/19 at 0807 hours, Licensed Nurse 20 was asked to come to Resident 136's room. Licensed Nurse 20 verified the call light was not placed within the resident's reach. Review of the MDS dated 10/16/19, showed Resident 136 was cognitively intact.

F577 SS=B Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 12/14/2019 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 10 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure the resident confidential identifying information was not made available to the public when three confidential resident rosters containing six resident names from three separate abbreviated surveys were observed in the survey binder. This failure violated the residents' right to privacy. Findings: On 11/7/19 at 1132 hours, an observation, interview, and concurrent facility document review was conducted with the Administrator. Near the lobby was a binder titled Survey Results with the results from the two previous recertification and abbreviated surveys. The Administrator was asked who was responsible for ensuring the survey results were placed in the binder. The Administrator stated he was, but on the weekends, the DON was responsible. The Administrator verified three resident rosters for three abbreviated surveys were located in the binder.

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v) FORM CMS-2567(02-99) Previous Versions Obsolete

F578 Event ID: U01H11 12/14/2019 Facility ID: CA060000164 If continuation sheet 11 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 12 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: 2. Review of Resident 657's POLST (undated) showed Section A (cardiopulmonary resuscitation), Do Not Attempt Resuscitation/DNR was checked. Section D (Information and Signatures) showed Resident 657 did not have an advance directive. Resident 657's physician signed the POLST without a signature from the resident or their legally recognized decision maker acknowledging the resuscitative measures desired for the resident. Review of the Advance Directive Acknowledgement, unsigned and undated, showed Resident 657 had an advance directive. On 11/13/19 at 1443 hours, an interview was conducted with Licensed Nurse 5. Licensed Nurse 5 verified the above findings and stated the resident or responsible party should have signed the POLST. Licensed Nurse 5 also verified there was no Advance Directive in Resident 657's medical record. Based on interview and medical record review, the facility failed to ensure the POLSTs for two of 34 final sampled residents (Residents 83 and 657) reflected the residents' or the residents' legal representatives' healthcare decisions. * The facility failed to ensure Resident 83's current POLST was signed by Resident 83's legally recognized decision maker before it was signed by the physician. * The facility failed to ensure Resident 657's current POLST was signed by the resident before it was signed by the physician. The facility failed to ensure no discrepancies existed between Resident 657's POLST and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 13 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the Advanced Directive Acknowledgement. These failures had the potential for the residents' advanced care planning decisions regarding their health care treatment options not being honored. Findings: 1. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19, and readmitted on 10/29/19. Review of the MDS dated 9/25/19, showed Resident 83 had severe cognitive impairment. Review of the POLST dated 10/8/19, showed Section A (cardiopulmonary resuscitation), Do Not Attempt Resuscitation/DNR was checked. Section D (Information and Signatures) showed the advance directive (no date provided) was available and reviewed. Resident 83's physician signed the POLST, however, the area for the signature of the resident or legally recognized decision maker was blank. Review of the Advance Directive Acknowledgment (undated) showed Resident 83 had not executed an Advance Directive. However, review of the previous medical record showed Resident 83 had an Advance Directive. On 11/8/19 at 0753 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 13. Licensed Nurse 13 verified the above findings and stated she did not know why the POLST was checked off and signed by the physician when the responsible party had not signed it.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 12/14/2019 Facility ID: CA060000164 If continuation sheet 14 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 15 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a safe and comfortable environment for one of 34 final sampled residents (Resident 449) and one nonsampled resident (Resident 450). The privacy curtain in Resident 449's room was not fully secured to the ceiling, and the ceiling had a loose tile. Both residents voiced a concern the water took an excessive amount of time to reach an acceptable temperature. These failures put the residents at risk for injury and caused the residents to be uncomfortable related to unacceptable water temperatures. Findings: Review of the facility's P&P titled Building Systems Water Systems and Temperature Control revised 4/2019 showed the water temperature for hot water used by residents was to be between 105 and 120 degrees F. 1a. On 11/7/19 at 0920 hours, an observation and concurrent interview was conducted in Resident 449's room. Resident 449 stated he sometimes got cold baths because the staff used towels and water from the sink to provide the bath. Resident 449 stated it was almost always a problem, and sometimes the water did not reach an acceptable temperature for over 20 minutes. The hot water was turned on and ran for three minutes. The water remained cold to the touch. Resident 449 also stated he was concerned about the condition of the privacy curtain tract attached to the ceiling. The tract was observed with white putty in multiple areas and was coming loose from the ceiling. Resident 449 stated he was worried about the curtain and tract falling on him and about the dust it could cause. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 16 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Medical record review for Resident 449 was initiated on 11/8/19. Resident 449 was admitted to the facility on 10/23/19. Review of Resident 449's MDS dated 10/30/19, showed Resident 449 was cognitively intact. On 11/12/19 at 0813 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor turned on the hot water in Resident 449's room at 0813 hours. The Maintenance Supervisor stated the acceptable range for the hot water was 105 to 120 degrees F. After five minutes of running the hot water, the water temperature was 89.4 degrees F. The Maintenance Supervisor stated the building was old and the staff needed to run the water until it got hot in the rooms at the end of the wing every four hours in order for the water to remain hot from the faucet. At 0820 hours, seven minutes after turning on the hot water, the water temperature reached 105 degrees F. The Maintenance Supervisor stated they checked random rooms every day for water temperatures. Review of the facility's document titled FPCC Room Water Temp Log dated November 2019 showed the water temperature in Resident 449's was last checked on 11/17/19, and the temperature was 114 degrees F. There was no documentation how long it took for the water to reach 114 degrees F. On 11/12/19 at 0822 hours, an interview was conducted with CNA 2. CNA 2 stated the water was always cold in the end rooms. CNA 2 stated she had to let the water run for a long time before it got warm enough. CNA 2 stated she had to schedule care for the residents based on when the water got hot. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 17 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. On 11/12/19 at 1056 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor in Resident 449's room. The Maintenance Supervisor observed the ceiling in Room A and verified the tile was loose and the privacy curtain tract pulled away from the ceiling with a slight pull on the privacy curtain. The Maintenance Supervisor stated the tract and tile needed to be fixed. 2. On 11/12/19 at 0826 hours, an interview was conducted with Resident 450 in the resident's room. Resident 450 stated it took about 20 minutes every day for the water in her room to get hot. Resident 450 stated she sometimes got bed baths and the CNAs used the water from the sink in her room. She stated she always had to wait for the water to get warm. Medical record review for Resident 450 was initiated on 11/12/19. Resident 450 was admitted to the facility on 7/25/19. Review of Resident 450's MDS dated 10/6/19, showed Resident 450 was cognitively intact. On 11/12/19 at 1056 hours, an observation was conducted in Resident 450's room. A licensed nurse was observed washing her hands at the sink for two minutes. When the Maintenance Supervisor checked the water temperature at the sink immediately after the licensed nurse used her hands in the sink, it was 112 degrees F. The Maintenance Supervisor stated the temperature was only a problem when the water had not been running for a while. Review of the facility's document titled FPCC Room Water Temp Log dated November 2019 showed the water temperature in Resident 450's room was last checked on 11/12/19, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 18 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the temperature was 110 degrees. There was no documentation how long it took for the water to reach an acceptable temperature or at what time the temperature was checked.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 12/14/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 19 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 20 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to notify the Long-Term Care Ombudsman in writing as soon as practicable when an immediate transfer or discharge was required due to the residents' urgent medical needs. The facility failed to send copies of the notice of transfers to the Long-Term Care Ombudsman for two of 34 final sampled residents (Residents 25 and 52). This posed the risk of the LongTerm Care Ombudsman not being aware of the circumstances should appeals be filed by the residents or their representatives regarding the transfers/discharges. Findings: 1. Medical record review for Resident 25 was initiated on 11/8/19. Resident 25 was readmitted to the facility on 10/24/19. Review of the facility's census information FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 21 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE showed Resident 25 was transferred out of the facility on 9/8/19, and 10/24/19. Review of Resident 25's medical record failed to show any documentation the Long-Term Care Ombudsman was notified when Resident 25 was transferred out of the facility. On 11/13/19 at 1122 hours, a concurrent interview and medical record review was conducted with the Medical Records Assistant. The Medical Records Assistant was asked if the Long-Term Care Ombudsman was notified of the above transfers. The Medical Records Assistant was unable to find documentation the Long-Term Care Ombudsman had been notified of Resident 25's transfer on 10/24/19. The Medical Records Assistant stated it must have been missed. 2. Medical record review for Resident 52 was initiated on 11/8/19. Resident 52 was readmitted to the facility on 10/29/19. Review of the facility's census information showed Resident 52 was transferred out of the facility on 1/19 and 10/29/19. Review of Resident 52's medical record failed to show any documentation the Long-Term Care Ombudsman was notified when Resident 25 was transferred to the acute care hospital. On 11/13/19 at 1122 hours, a concurrent interview and medical record review was conducted with the Medical Records Assistant. The Medical Records Assistant was asked if the long term care ombudsman was notified of the above transfers. The Medical Records Assistant was unable to find documentation the long term care ombudsman had been notified of Resident 52's transfer on 10/29/19. The Medical Records Assistant stated it must have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 22 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE been missed.

F645 SS=D PASARR Screening for MD & ID CFR(s): 483.20(k)(1)-(3)

F645 12/14/2019 §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k) (3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section(i)The preadmission screening program under paragraph(k)(1) of this section need not provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 23 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b) (3) or is a person with a related condition as described in 435.1010 of this chapter. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to complete the Preadmission Screening and Record Review (PASRR) for one of 34 final sampled residents (Resident 145) with diagnoses including psychosis. The facility failed to accurately assess Resident 145's conditions to determine the level of PASRR. This posed the risk of the resident not receiving specialized care and services appropriate for their condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 24 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Medical record review for Resident 145 was initiated on 11/7/19. Resident 145 was admitted to the facility on 10/19/19, with diagnoses including psychosis. Review of Resident 145's Physician Orders showed an order dated 10/19/19, for Risperidal (antipsychotic medication) 0.5 mg one tablet daily by mouth for psychotic mood disorder. Review of Resident 145's PASRR Level 1 Screening Document dated 10/19/19, showed Level 1 - Negative. The form showed Section V - Mental Illness question 26 was left blank (the resident has a diagnosed mental disorder such as psychosis or mood disorder). Question 28 was left blank (the resident has been prescribed psychotropic medications). On 11/12/19 at 0907 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 15. Licensed Nurse 15 stated the licensed nurse who admitted the resident should have interviewed the resident or responsible party and checked the medical records for any diagnosis or prescribed psychotropic medications. Licensed Nurse 15 verified the Mental Illness section on Resident 145's PASRR screening was not completed. On 11/12/19 at 1609 hours, an interview and medical record review was conducted with the DON. The DON verified questions 26 and 28 in Section V should have been answered yes.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 02/06/2020 §483.21(b) Comprehensive Care Plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 25 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 26 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and medical record review, the facility failed to develop comprehensive plans of care for four of 34 final sampled residents (Residents 1, 45, 100, and 142). * The facility failed to develop a comprehensive care plan to address Resident 100's frequent severe pain. * The facility failed to develop a comprehensive care plan to address Resident 1's use of oxygen and bilateral side rails. * The facility failed to develop a comprehensive care plan to address Resident 142's use of bilateral side rails and apixaban (anticoagulant medication) treatment. * The facility failed to ensure a care plan problem was developed to address Resident 45's suprapubic catheter. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Medical record review for Resident 100 was initiated on 10/7/19. Resident 100 was admitted to the facility on 6/25/19. Review of the Physician Orders showed an order dated 7/3/19, to administer Norco (narcotic pain medication) 5/325 mg two tablets by mouth every six hours as needed for pain management and an order dated 6/25/19, to monitor every shift for pain using the pain intensity scale from 0 to 10 with 0 = no pain, 14 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, and 10 = very severe pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 27 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Pain Assessment Flow Sheets and Medication Administration Records for September, October and November 2019 showed Resident 100 had been assessed to have severe pain (8 out of 10) almost every shift and was administered the PRN (as needed) Norco tablets to manage the pain. Review of the plan of care failed to show a comprehensive care plan was developed to address Resident 100's frequent severe pain. On 11/12/19 at 0655 and 0709 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 7. Licensed Nurse 7 verified Resident 100 was constantly complaining of severe generalized body pains and was administered the Norco tablets to manage her pain. Licensed Nurse 7 reviewed Resident 100's medical record and verified there was no care plan problem developed to address Resident 100's pain. Cross reference to F697. 2. On 11/7/19 at 1126 hours, Resident 1 was observed lying in bed with bilateral side rails elevated. Resident 1 was receiving oxygen at 4 liters per minute through a nasal cannula (an oxygen tube with two prongs to fit into the nostrils to administer the oxygen). Medical record review for Resident 1 was initiated on 11/7/19. Resident 1 was readmitted to the facility on 10/7/19. Review of the Physician Orders showed an order dated 10/22/19, for oxygen at 4 liters per minute via nasal cannula as needed for shortness of breath, and to monitor the oxygen saturation (the amount of oxygen in the blood). Review of Resident 1's plan of care failed to show a care plan problem was developed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 28 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE address Resident 1's use of oxygen and side rails. On 11/12/19 at 0742 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 15. Licensed Nurse 15 reviewed the medical record and verified there were no care plan problems developed to address Resident 1's use of oxygen and side rails. (Cross reference to

F695) 3a. Resident 142 was observed on 11/7/19 at 0814 hours, in the bed with the left side rail elevated. On 11/7/19 at 0900 hours, 11/8/19 at 1241 hours, and 11/12/19 at 0706 and 0836 hours, Resident 142 was observed with bilateral side rails elevated. On 11/12/19 at 0836 hours, an interview was conducted with CNA 5. CNA 5 was asked if Resident 142's side rails were always elevated. CNA 5 stated yes. CNA 5 stated she sometimes only raised the right side rail, but she usually put both side rails up for the fall prevention for Resident 142. Medical record review for Resident 142 was initiated on 11/7/19. Resident 142 was admitted to the facility on 10/11/19. Review of Resident 142's medical record failed to show a care plan problem was developed to address the use of side rails. On 11/12/19 at 0838 hours, an interview and concurrent medical record review for Resident 142 was conducted with the DON. The DON was asked if a care plan problem should have been developed to address the use of side rails for Resident 142. The DON stated yes. However, the DON was unable to show Resident 142's plan of care had a care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 29 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE problem addressing the use of side rails. (Cross reference to F700) b. Review of Resident 142's Admission Orders Record Continuation showed an order dated 10/11/19, to administer apixaban 5 mg one tablet by mouth twice a day for atrial fibrillation. Review of 142's plan of care failed to show a care plan problem was developed to address the apixaban treatment. On 11/8/19 at 1142 hours, an interview and concurrent medical record review for Resident 142 was conducted with Licensed Nurse 5. Licensed Nurse 5 verified the plan of care did not address the apixaban treatment for Resident 142. 4. On 11/7/19 at 0723 and 0749 hours, Resident 45 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag. The urinary drainage bag was observed resting on the bed. Medical record review for Resident 45 was initiated on 11/7/19. Resident 45 was readmitted to the facility on 9/22/19. Review of the general acute care hospital's documentation dated 9/18/19, showed Resident 45 had a history of recurrent UTIs. Review of Resident 45's plan of care failed to show a care plan problem was developed to address the suprapubic catheter (a urinary catheter inserted through the lower abdomen directly into the bladder). On 11/7/19 at 1418 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 18. Licensed Nurse 18 verified there was no care plan problem developed to address Resident 45's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 30 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE suprapubic catheter care. Cross reference to

F690.

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 12/14/2019 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 31 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure a communication device was provided to one of 43 final sampled residents (Resident 145). Resident 145 did not speak English. This failure had the potential of Resident 145 not being able to understand and communicate their care needs to the staff. Findings: Review of Resident 145's medical record was initiated on 11/7/19. Resident 145 was admitted to the facility on 10/19/19. On 11/12/19 at 1030 hours, CNA 15 was observed in Resident 145's room. CNA 15 asked Resident 145 if he could stand up. The resident looked at CNA 15 and did not respond to her request. CNA 15 stated to Resident 145, "Let's go shower." The resident looked at CNA 15 and did not respond. CNA 15 again requested for Resident 145 to stand up. The resident stayed in his bed. CNA 15 told Resident 145 to sit in his chair and pointed to the chair. Resident 145 followed the direction and moved to his chair. Review of the MDS dated 10/25/19, showed Resident 145 spoke a foreign language and needed an interpreter to communicate with the physician and staff. Review of Resident 145's Preadmission Screening and Record Review (PASRR) dated 10/19/19, showed Resident 145 spoke a foreign language and responded better with family around, otherwise was unable to follow directions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 32 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 145's care plan showed a care plan problem dated 10/24/19, to address a communication problem. The interventions included to provide a communication book in Resident 145's preferred language. On 11/12/19 at 1048 hours, a communication board in Resident 145's preferred language was noted hanging on the wall in the hallway between rooms D and E. On 11/13/19 at 0837 hours, an interview was conducted with CNA 15. CNA 15 was asked how she communicated with Resident 145. CNA 15 stated she spoke to the resident in English. CNA 15 stated Resident 145 only knew how to say "peepee" and "hungry" in English and she had only heard him speak full sentences when his family visited and they spoke in their preferred language. When asked if she used any other communication tools to communicate with the resident, CNA 15 stated no. On 11/13/19 at 0845 hours, an interview was conducted with CNA 16. CNA 16 stated the facility sometimes used Resident 145's roommates to notify staff when the resident needed something by informing them to press the call light for him. CNA 16 stated Resident 145 did not ask for anything more than water or the bathroom because he did not know the English words for them. CNA 16 stated the way she knew what the resident needed was by looking at him and trying to figure out what he needed. CNA 16 stated if she brought Resident 145 something to drink and if he did not touch it, she knew he didn't like it. CNA 16 stated if she brought the resident something he liked, he would smile and that is how she knew what he needed. CNA 16 stated the facility did not have translators or translator phones. When CNA 16 was asked if she communicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 33 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in any other way with Resident 145 other than speaking to him in English, she stated there was no other way other than via the family when they visited. On 11/13/19 at 1450 hours, an interview was conducted with Licensed Nurse 29. Licensed Nurse 29 was asked how Resident 145 communicated his needs. Licensed Nurse 29 stated the resident knew how to use the call light but did not speak any English. Licensed Nurse 29 stated, one day Resident 145 needed something important but staff could not figure out what the resident needed. Licensed Nurse 29 stated she called the family but they were unavailable. Licensed Nurse 29 stated she did not know how to communicate to the resident so they were calling the family. Licensed Nurse 29 was asked if she used the communication board with Resident 145. Licensed Nurse 29 stated she had used it before, but she could not use it to communicate the word for a specific family member to the resident that day. Licensed Nurse 29 was asked to show how she used the communication board. Licensed Nurse 29 opened the communication board and showed the communication board included the word for the specific family member. Licensed Nurse 29 stated she understood the word for the family member was written on the communication board in English but she did not know how to read the word in the resident's preferred language. Licensed Nurse 29 was asked if she received training on how to use the communication board. Licensed Nurse 29 stated she did not and stated the facility expected them to know how to use it. Licensed Nurse 29 stated she should have received training on how to use the communication board so she could communicate with the residents who spoke a foreign language. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 34 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F684 Quality of Care CFR(s): 483.25

F684 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/14/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: 6. Review of the Highlights of Prescribing Information for Eliquis from the Food and Drug Administration, Section Medication Guide, showed stopping apixaban for atrial fibrillation may increase risk of having a stroke. It indicated to refill prescriptions before running out, emphasizing the importance of not missing a dose. Medical record review for Resident 657 was initiated on 11/7/19. Resident 657 was readmitted to the facility on 11/5/19. On 11/7/19 at 0945 hours, an interview was conducted with Resident 657. Resident 657 stated she was worried because she had not received all of her medications for the two days she was residing at the facility. Review of the History and Physical Examination dated 11/7/19 showed Resident 657 had a history of atrial fibrillation (an irregular heartbeat that can lead to blood clots, stroke, and heart failure). Review of MDS dated 11/7/19 Showed Resident 657 was cognitively intact and was able to make her needs known. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 35 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 657's Admission Orders Record Continuation dated 11/5/19 showed a physician's order for apixaban 2.5 mg one tablet twice a day by mouth for atrial fibrillation. It also showed a physician's order for glimepiride 4 mg one tablet daily by mouth for diabetes mellitus. Review of Resident 657's Medication Administration Record dated 11/19 failed to show documented evidence one tablet of apixaban was administered to Resident 657 on 11/6 and 11/7/19. It also failed to show one tablet of glimepiride was administered to Resident 657 on 11/6 and 11/7/19. On 11/7/19 at 1000 hours, an interview was conducted with Licensed Nurse 21. Licensed Nurse 21 stated when a hospice resident was admitted, the hospice nurse would usually follow the resident within a few hours of admission. Licensed Nurse 21 stated the hospice nurse was usually in charge of medications, but if they were not available, then the facility licensed nurses would order the medications from their pharmacy. On 11/7/19 at 1111 hours, a follow-up interview was conducted with Licensed Nurse 21. Licensed Nurse 21 stated she just called the physician and notified her DON about the missing medications. Licensed Nurse 21 stated DON gave her authorization to order the medications STAT. Licensed Nurse 21 stated when she called one of the hospice case managers they informed her not to worry about the medications since Resident 657 was discharging soon. Licensed Nurse 21 was asked if she notified the physician of this and she stated she did not. Licensed Nurse 21 verified the last time Resident 657 received her apixaban and glimepiride was when she was at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 36 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the hospital on 11/5/19. On 11/7/19 at 1206 hours, another follow-up interview was conducted with Licensed Nurse 21. Licensed Nurse 21 verified she did not document when she called hospice about the missing medications. Licensed Nurse 21 stated she only worked for three hours that day and she endorsed the information to Licensed Nurse 15. On 11/7/19 at 1428 hours, a follow-up interview was conducted with Licensed Nurse 21 and Licensed Nurse 15. Licensed Nurse 21 stated she endorsed Licensed Nurse 15 regarding the missing medications. Licensed Nurse 15 verified this information. Licensed Nurse 21 stated on Resident 657's Medication Administration Record dated 11/19, a box marked as "0" was a documentation technique she used when a medication was not administered. Licensed Nurse 21 confirmed the resident's glimepiride and apixaban medication was not delivered until noon on 11/7/19 and was unsure what the "N" marking meant on the Medication Administration Record on 11/6/19. Licensed Nurse 21 verified she did not administer apixaban or glimepiride to Resident 657 on 11/6 or 11/7/19. On 11/13/19 at 1416 hours, an interview was conucted with the DON. The DON verified apixaban and glimepiride were not given to Resident 657 on 11/6 or 11/7/19. DON also verified she was contacted by Licensed Nurse 21 on 11/7/19. DON stated she expected the physician to have been notified on the day the medication was first discovered as missing. On 11/13/19 at 1425 hours, an interview was conducted with the DON and Licensed Nurse 21. Licensed Nurse 21 verified on 11/6/19, when she discovered the missing medications, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 37 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she did endorse Licensed Nurse 25 but did not contact the physician. Licensed Nurse 21 stated the first time she contacted the physician was on 11/7/19. Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure five of 34 final sampled residents (Residents 45, 50, 69, 83, and 657) and one unnecessary medication sampled resident (Resident 34) attained and maintained their highest practicable physical well-being. * The facility failed to follow the physician's order for Resident 83 to be kept on an NPO (nothing by mouth) status. Resident 83 was observed drinking water given by the CNA assigned to him. In addition, the facility failed to schedule an appointment for modified barium swallow (MBS) study ordered 13 days ago for Resident 83. These failures placed Resident 83 at high risk for aspiration and a delay in intervention and treatment. * The facility failed to notify the physician when Resident 69's blood sugar level was greater than 200 mg/dL in accordance with the physician's order. This failure posed the risk of Resident 69's high blood sugar (hyperglycemia) not being treated in a timely manner. * The facility failed to administer calcium with vitamin D tablets to Resident 34 for the month of November 2019 according to the physician's order. This failure created the risk of medical complications for the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 38 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE * The facility failed to ensure Resident 45's smart monitoring device for his implanted ICD (internal cardiac defibrillator) was kept plugged into the electrical outlet. This failure had the potential for the physician to have delayed or incomplete data regarding Resident 45's heart rhythm. * The facility failed to ensure Resident 50 had a physician's certification of terminal illness in the medical record for the prior two certification periods. This failure had the potential for uncoordinated care between the facility and the hospice provider. * The facility failed to administer apixaban (a medication used to treat and prevent blood clots and stroke in people with atrial fibrillation) and glimepiride (a medication used to improve blood sugar control) to Resident 657 as ordered by the physician. This had the potential to negatively impact the resident's well-being. Findings: 1. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19. Review of the Admission MDS dated 9/25/19, showed Resident 83 had severe cognitive impairment. a. On 11/8/19 at 0810 hours, Resident 83 was observed sitting in a wheelchair in his room. CNA 12 was in the room. Resident 83 was heard asking CNA 12 for a glass of water with ice. CNA 12 was observed getting water from a pitcher on top of a medication cart parked outside of Resident 83's room. CNA 12 filled the 4 ounce cup with water (no ice) and gave to Resident 83. Resident 83 quickly drank FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 39 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE approximately three quarters of the water from a four ounce cup. Resident 83 was observed clearing his throat after drinking the water. On 8/11/19 at 0812 hours, an interview was conducted with CNA 12. CNA 12 verified the above findings and stated Resident 83 could drink water and was not NPO. CNA 12 stated this was her first time taking care of Resident 83. Review of the Physician's Telephone Orders dated 10/30/19, showed Resident 83 was to be NPO. Review of the plan of care showed a care plan problem dated 10/30/19, to address Resident 83's risk for aspiration due to decline in swallowing function. Resident 83 was to be on strict NPO and aspiration (inhalation of food or liquids into the lungs) precautions. On 11/8/19 at 0838 hours, an interview was conducted with Licensed Nurse 3. Licensed Nurse 3 stated Resident 83 was NPO. Licensed Nurse 3 stated she did not inform the CNA assigned to Resident 83 prior to the start of her shift because "...most of them already know." Licensed Nurse 3 was made aware Resident 83 was given water by the CNA. On 11/8/19 at 1646 hours, Licensed Nurse 13 was observed at her medication cart passing medications next to Resident 83's room. Licensed Nurse 13 stated she already received a report from the outgoing nurse, however, was not made aware Resident 83 was given water when he was supposed to be NPO. On 11/8/19 at 1648 hours, a follow-up interview was conducted with Licensed Nurse 3. When asked if she had notified the physician regarding Resident 83 drinking water when he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 40 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was supposed to be NPO, Licensed Nurse 3 stated no. Licensed Nurse 3 stated Resident 83 was given ice chips by the SLP during therapy so he should be okay. On 11/12/19 at 0802 hours, an interview was conducted with the SLP. The SLP stated Resident 83 had a severe impairment of the oropharyngeal swallow and was a high risk for aspiration. The SLP stated if Resident 83 was given water to drink, he would aspirate. The SLP stated she gave ice chips to Resident 83 during therapy, but, even with ice chips, Resident 83 coughed. The SLP stated she was not aware Resident 83 was given water to drink. The SLP stated that would have been good information to know since Resident 83 was recently hospitalized for aspiration pneumonia. b. Review of Resident 83's Physician's Telephone Orders dated 10/30/19, showed an order for a modified barium swallow study to determine the swallowing status due to oral and oropharyngeal dysphagia (difficulty swallowing). On 11/12/19 at 0755 hours, the SLP was overheard asking Licensed Nurse 15 why the order for the MBS study was not carried out and if she could make sure this was done today. On 11/12/19 at 0802 hours, an interview was conducted with the SLP. The SLP verified there was an order for a MBS on 10/30/19, which was not scheduled yet that was why she followed up with the licensed nurse today. On 11/12/19 at 0946 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 15. Licensed Nurse 15 verified the MBS study had not been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 41 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE scheduled and she did not know why. Licensed Nurse 15 was unable to provide documentation to show an attempt was made to schedule the MBS study when it was ordered on 10/30/19. 2. Medical record review for Resident 69 was initiated on 11/7/19. Resident 69 was admitted to the facility on 2/11/03. Review of Resident 69's Physician Orders showed an order dated 10/3/19, to check the blood sugar level before breakfast and call the physician if the blood sugar level was greater than 200 mg/dL. Review of the Medication Administration Record for November 2019 showed the blood sugar levels were scheduled to be checked daily at 0630 hours and to call the physician if the blood sugar level was greater than 200 mg/dL. The following blood sugar levels greater than 200 mg/dL were recorded dated: - 11/5/19, 230 mg/dL; - 11/6/19, 255 mg/dL; and - 11/8/19, 240 mg/dL. Review of the medical record failed to show documentation the physician was notified when the blood sugar level was greater than 200 mg/dL on 11/5 and 11/8/19. On 11/8/19 at 1152 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 3. Licensed Nurse 3 verified the above findings and stated she was not aware about Resident 69's blood sugar level of 240 mg/dL this morning. Licensed Nurse 3 was unable to provide documentation to show the physician was informed when the blood sugar levels were greater than 200 mg/dL on 11/5 and 11/8/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 42 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Medical record review for Resident 34 was initiated on 11/12/19. Resident 34 was readmitted to the facility on 7/21/18. Review of the Physician Orders showed an order dated 9/29/19, for calcium with vitamin D 500 mg-200 iu one tablet daily at 1700 hours. Review of the Medication Administration Record for November 2019 showed the calcium with vitamin D tablet was scheduled to be given daily at 1700 hours as ordered. However, there was no documentation to show Resident 34 was administered the calcium with vitamin D tablet for November 2019. Review of the laboratory results showed Resident 34's calcium and vitamin D levels were borderline low as follows: - On 8/8/19, calcium level was 8.4 mg/dL (normal range: 8.4-10.6); - On 10/29/18, vitamin D level was 34 ng/mL (normal range: 30-100). On 11/12/19 at 1339 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 16. Licensed Nurse 16 verified the calcium with vitamin D was not administered for the month of November 2019 to Resident 34, and stated it was missed during the recapitulation of the physician's orders. 4. Review of the ICD and smart monitoring device's manufacturer's reference guide showed the smart monitoring device wirelessly and automatically collects data from the pacemaker or defibrillator and transmits it to the service center, which allows clinics to review and assess resident transmissions and device data via a secure website. This allows clinics the capability to replace device interrogation during in-office follow-up visits and to provide early detection of arrhythmias. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 43 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/7/19 at 0723 hours, Resident 45 was observed lying in bed. A small circular implant was observed protruding on Resident 45's left upper chest. Medical record review for Resident 45 was initiated on 11/7/19. Resident 45 was readmitted to the facility on 9/22/19. Medical record review for Resident 45 showed a Pacemaker Alert. Resident 45 had an internal cardiac defibrillator (ICD) implanted on 4/4/19. Review of Resident 45's Physician Orders showed an order dated 9/22/19, to keep Resident 45's smart monitoring device plugged in and to check every shift to ensure the smart monitoring device was plugged in. Review of Resident 45's plan of care showed a care plan problem dated 9/22/19, to address Resident 45's alteration in cardiac function related to the pacemaker. The care plan problem showed the pacemaker was implanted into the resident's left upper chest. The approaches included to keep the smart monitoring device on the wire shelf (at the resident's bedside) and plugged in. On 11/8/19 at 0743 hours, Resident 45 was observed lying in bed. The smart monitoring device was observed sitting on a wire shelf at Resident 45's bedside, but was not plugged into the electrical outlet. On 11/8/19 at 0747 hours, Licensed Nurse 22 was asked to come to Resident 45's room. Licensed Nurse 22 verified the smart monitoring device was not plugged into the electrical outlet. License Nurse 22 stated the nurses were supposed to check every shift to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 44 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ensure the smart monitoring device was plugged in. Licensed Nurse 22 stated he was not sure how long the smart monitoring device was not plugged in. On 11/8/19 at 1202 hours, a telephone interview was conducted with the ICD and smart monitoring device's manufacturer's Customer Solutions Representative. The Customer Solutions Representative stated the ICD implant sends data (such as the resident's heart rhythm or arrhythmias [irregular heart rate or rhythm]) to the smart monitoring device, which wirelessly transmits a report (daily) that the physician can review. The Customer Solutions Representative verified the smart monitoring device had to be kept plugged into the electrical outlet for it to work. 5. Medical record review for Resident 50 was initiated on 11/8/19. Resident 50 was admitted to the facility on 2/11/19. Review of Resident 50's Physician Orders showed an order dated 2/11/19, to admit to hospice under routine level of care. Review of Resident 50's medical record failed to show a physician's certification of terminal illness for the periods between August through October 2019 and October through December 2019. On 11/12/19 at 1357 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 2. Licensed Nurse 2 reviewed Resident 50's medical record and verified the physician's certification of terminal illness for the certification periods beginning 8/10 through 10/8/19 and 10/9 through 12/7/19, were not in the medical record.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 12/14/2019 SS=G FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 45 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for two of 34 final sampled residents (Residents 73 and 135). * Resident 73 was incontinent and had no pressure ulcers upon readmission to the facility on 2/6/19. Resident 73 developed a Stage 2 pressure ulcer on the sacrococcyx (tailbone) on 5/25/19, which had deteriorated to unstageable on 7/29/19. Resident 73's sacrococcyx pressure ulcer was observed without a dressing and the pressure ulcer was observed covered in a large amount of feces. The facility failed to provide appropriate and necessary nursing services to ensure Resident 73 did not develop a pressure ulcer in the facility and failed to ensure the pressure ulcer did not deteriorate. * Resident 135 was dependent on the staff for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 46 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bed mobility and had no pressure ulcers upon readmission to the facility. Resident 135 developed a blood-filled blister to the right elbow which had deteriorated to a Stage 4 pressure ulcer while at the facility. The facility failed to develop and implement a care plan problem to address the blood-filled blister when it was discovered and after it had ruptured and deteriorated to a Stage 3 pressure ulcer. The facility failed to provide nursing services to prevent the development and worsening of Resident 135's pressure ulcer. Findings: Review of the facility's P&P titled Pressure Injury Management revised 3/27/17, showed a resident who has pressure injuries (ulcers) will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. A pressure injury is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. Although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing factors to the development of pressure injuries. Review of the National Pressure Ulcer Advisory Panel's (NPUAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers dated 2014 showed maintaining skin integrity is essential in the prevention of pressure ulcers. The recommendations included to keep the skin clean and dry and to develop and implement an individualized continence management plan. Cleanse the skin promptly following episodes of incontinence. Incontinence can lead to prolonged skin exposure to excess moisture FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 47 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and chemical irritants in urine and feces. Repositioning individuals is an important component in the prevention of pressure ulcers. The underlying cause and formation of pressure ulcers is multifaceted; however, by definition, pressure ulcers cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in ischemia and inevitable tissue damage. Repositioning involves a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Individuals who cannot reposition themselves will require assistance. The recommendations included to reposition all individuals at risk of developing pressure ulcers or with existing pressure ulcers. Support surfaces are an important element in pressure ulcer treatment because they provide an environment that enhances perfusion of injured tissue. However, support surfaces alone neither prevent nor heal pressure ulcers. The NPUAP defines the pressure ulcer stages as follows: - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 48 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. 1. On 11/7/19 at 0715 hours, Resident 73 was observed lying on her right side on a low air loss mattress and had an indwelling urinary catheter in place. Medical record review for Resident 73 was initiated on 11/7/19. Resident 73 was readmitted to the facility on 2/6/19, and was transferred out of the facility on 8/4/19. Resident 73 was then transferred back to the facility on 8/5/19. Review of Resident 73's Resident Admission Assessment dated 2/6/19, showed Resident 73 was totally dependent on the staff for bed mobility and toileting. The admission assessment showed Resident 73 had an old scar on the sacrococcyx, but did not have a pressure ulcer. Review of Resident 73's Skin & Body Assessment dated 2/7/19, showed Resident 73 did not have a pressure ulcer. Review of Resident 73's plan of care showed a care plan problem dated 2/6/19, to address Resident 73's risk for the development of pressure ulcers secondary to decreased mobility, edema, and incontinence. The care plan problem showed Resident 73 had a history of pressure ulcers but was not readmitted to the facility with pressure ulcers. The approaches included to turn and reposition the resident as needed for comfort and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 49 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure relief and to provide good skin care daily. A care plan problem dated 2/6/19, to address Resident 73's risk for skin breakdown and recurrent skin breakdown secondary to impaired mobility, incontinence, and a history of pressure ulcers showed the approaches included to turn and reposition Resident 73 every two hours and as needed. Review of Resident 73's MDSs dated 3/8, 6/7, and 9/6/19, showed Resident 73 was totally dependent on two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed) and toilet use (including how the resident was cleaned after elimination and pad changes). The MDSs also showed Resident 73 was always incontinent of bowel movements. Review of the Nurses Notes for Resident 73 dated 5/25/19, showed the CNA reported a skin issue to the licensed nurse. Resident 73 was noted with a Stage 2 pressure ulcer to the sacrococcyx measuring 3 cm (length) x 2 cm (width) x (depth illegible). The notes showed the staff was educated to reposition Resident 73 every two hours and to keep the resident on her sides as much as possible. Review of Resident 73's plan of care showed a care plan problem dated 5/25/19, to address Resident 73's altered skin integrity related to the Stage 2 sacrococcyx pressure ulcer. The contributing factors for further skin breakdown and slow healing included a history of pressure ulcers and incontinence. The approaches included to turn and reposition Resident 73 every two hours and as needed, provide prompt pericare to maintain dryness and comfort, provide skin care during ADL care, and keep the area clean and dry. The care plan problem was revised on 7/25/19, to show FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 50 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the sacrococcyx pressure ulcer had deteriorated to a Stage 3 and was revised again on 7/29/19, to show the sacrococcyx pressure ulcer was then unstageable. Review of the Nurses Notes dated 7/25/19, showed Resident 73's sacrococcyx pressure ulcer was reassessed and was noted to have deteriorated to a Stage 3 with 80% yellow slough (dead tissue that may have a yellow or white appearance) and 20% granulation (pink or beefy red tissue with a shiny, moist, granular appearance). The wound size increased from 1.5 cm (length) x 1.5 cm (width) x superficial (depth) to 3 cm (length) x 3 cm (width) x 0.2 cm (depth). The physician was notified and ordered a wound consultation. The licensed nurse documented to turn and reposition Resident 73 every two hours and as needed. A nursing entry dated 7/29/19, showed Resident 73 was examined by the physician for a wound consultation regarding the sacrococcyx pressure ulcer and noted the wound appeared to be unstageable due to necrotic (non-viable tissue due to reduced blood supply) tissue. An entry dated 8/4/19, showed Resident 73 was transferred to the general acute care hospital for a GT replacement. Review of the electronic health record's "Census" tab showed Resident 73 returned to the facility on 8/5/19. Review of Resident 73's Weekly Wound Assessment dated 8/5/19, showed Resident 73's sacrococcyx pressure ulcer was a Stage 4, measuring 4.6 cm (length) x 3.5 cm (width) x 0.5 cm (depth). On 11/5/19, the Stage 4 sacrococcyx pressure ulcer measured 1.2 cm (length) x 1.2 cm (width) x 1 cm (depth). Review of Resident 73's plan of care showed a care plan problem dated 8/6/19, to address an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 51 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE existing Stage 4 sacrococcyx pressure ulcer. The approaches included to turn and reposition the resident every two hours and as needed. A care plan problem dated 8/6/19, to address Resident 73's ADL deficits related to cognitive loss and CVA (cerebrovascular accident or stroke), requiring assistance for bed mobility and toilet use showed to assist Resident 73 with ADL care to the extent needed, turn and reposition the resident every two hours, and provide incontinence care. A care plan problem dated 8/13/19, to address Resident 73's incontinence showed the resident was totally incontinent. The approaches included to provide incontinence care after each incontinent episode and observe the skin for any abnormalities during toileting and/or changing. On 11/12/19 at 0513 hours, Resident 73 was observed lying on her right side on a low air loss mattress. On 11/12/19 at 0646 hours, Resident 73 was observed lying on her right side on a low air loss mattress. On 11/12/19 at 0652 hours, CNA 3 was observed providing care to a resident. CNA 3 was asked the last time he provided care to Resident 73. CNA 3 stated he last cleaned and turned Resident 73 at the beginning of his shift and he had not had time to clean or reposition the resident again because he was the only CNA on duty. On 11/12/19 at 0657 hours, an interview was conducted with Licensed Nurse 11. When asked if he provided incontinence care and turned/repositioned Resident 73 during his shift, Licensed Nurse 11 stated no. Licensed Nurse 11 acknowledged the residents were not being cleaned and turned every two hours. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 52 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/12/19 at 0722 hours, Resident 73 was observed lying on her right side on a low air loss mattress. On 11/12/19 at 0830 hours, an observation of Resident 73 was conducted with CNA 8. Resident 73 was observed lying on her right side, her position was unchanged from the previous observations (beginning at 0513 hours). CNA 8 turned Resident 73 to check if Resident 73 had a bowel movement. Resident 73 was observed lying in a large amount of soft feces. Resident 73's sacrococcyx pressure ulcer was observed with no dressing in place and the wound was observed covered with feces. CNA 8 verified the finding. Resident 73's sacrococcyx pressure ulcer was approximately the size of a dime and appeared deep. The observation of the area surrounding the wound showed it was red. CNA 8 stated she was going to call the licensed nurse. On 11/12/19 at 0837 hours, an observation of Resident 73 was conducted with Licensed Nurse 12. Licensed Nurse 12 verified there was no dressing on Resident 73's sacrococcyx pressure ulcer and it was covered in feces. Licensed Nurse 12 verified the pressure ulcer was supposed to be kept clean and dry and an intact dressing was supposed to cover the sacrococcyx pressure ulcer. Licensed Nurse 12 verified Resident 73 was supposed to be provided incontinence care every two hours and as needed and was supposed to be turned/repositioned at least every two hours to prevent the pressure ulcer from worsening. Licensed Nurse 12 verified Resident 73's pressure ulcer was facility acquired. When asked how the pressure ulcer could have developed, Licensed Nurse 12 stated it could have developed from pressure and moisture. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 53 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Sub-Acute Daily Staffing for July 2019 showed the census ranged from 24 to 29 residents. There was only one CNA on duty for the 11 PM to 7 AM shifts on the following dates: 7/3, 7/5, 7/6, 7/8, 7/9, 7/14, 7/15, 7/18, 7/20, 7/21, 7/26, 7/27, and 7/30/19. On 7/7, 7/13, 7/19, and 7/25/19, there were two CNAs scheduled, but the second CNA worked less than 1.45 hours on those days. Resident 73's sacrococcyx pressure ulcer deteriorated to a Stage 3 on 7/25/19. On 7/29/19, Resident 73's sacrococcyx pressure ulcer worsened to unstageable due to the presence of necrotic tissue. On 16 of the (11 PM to 7 AM) shifts prior to Resident 73's sacrococcyx pressure ulcer deteriorating, only one CNA was on duty to turn/reposition and provide incontinence care every two hours and as needed for 24 to 29 residents. Cross reference to F725. 2. On 11/7/19 at 1125 hours, Resident 135 was observed lying on her left side on a low air loss mattress and had a dressing in place to her right elbow. Medical record review for Resident 135 was initiated on 11/7/19. Resident 135 was readmitted to the facility on 3/17/17. Review of Resident 135's Resident Admission Assessment dated 3/17/17, showed Resident 135 was totally dependent on the staff for bed mobility and had no pressure ulcers on readmission. Review of Resident 135's plan of care showed a care plan problem dated 10/15/17, to address Resident 135's ADL deficits due to cognitive loss and CVA/weakness. The approaches included to turn and reposition the resident every two hours. A care plan problem dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 54 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/15/17, to address Resident 135's risk for skin breakdown showed the approaches included to turn and reposition Resident 135 every two hours and as needed. Review of Resident 135's MDSs dated 7/5/19 and 10/24/19, showed Resident 135 was totally dependent on two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed). Review of the Licensed Nurse Progress Notes dated 8/15/19, showed Resident 135 had a right elbow abrasion which had healed and had no pressure ulcers. Review of the Nurses Notes showed an entry dated 8/16/19, showing Resident 135 was noted with a blood-filled blister measuring 2.1 cm (length) x 2 cm (width) to the right elbow. The nurses' note showed the skin breakdown was most likely caused by friction as the resident had bilateral upper extremity contractures. Review of the Nurses Notes for Resident 135 showed an entry dated 8/28/19, showing the blood-filled blister on Resident 135's right elbow opened and was a Stage 3 pressure ulcer measuring 1.8 cm (length) x 1.5 cm (width) x 0.3 cm (depth). The pressure ulcer was assessed as 80% granulation and 20% slough. Review of Resident 135's plan of care failed to show a care plan problem was developed to address the right elbow blood-filled blister and failed to show a care plan problem was developed to address the Stage 3 pressure ulcer to Resident 135's elbow after the bloodfilled blister had ruptured. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 55 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Weekly Pressure Ulcer Report dated 9/23/19, showed Resident 135's pressure ulcer to the right elbow was assessed as a Stage 4 measuring 2 cm (length) x 2.1 cm (width) x 0.3 cm (depth). Review of Resident 135's plan of care showed a care plan problem dated 10/31/19, to address Resident 135's Stage 4 pressure ulcer to the right elbow. The approaches included to turn and reposition the resident every two hours and as needed. The care plan problem to address the Stage 4 pressure ulcer to Resident 135's right elbow was not developed until over a month after Resident 135's pressure ulcer deteriorated from a Stage 3 to a Stage 4 pressure ulcer. On 11/12/19 at 0511 and 0646 hours, Resident 135 was observed lying on her left side on a low air loss mattress. On 11/12/19 at 0652 hours, CNA 3 was observed providing care to a resident. CNA 3 was asked when was the last time he provided care to Resident 135. CNA 3 stated he last cleaned and turned Resident 135 at the beginning of his shift and he had not had time to clean or reposition the resident again because he was the only CNA on duty. On 11/12/19 at 0657 hours, an interview was conducted with Licensed Nurse 11. Licensed Nurse 11 stated he only turned/repositioned Resident 135 and one other resident during his shift. Licensed Nurse 11 stated he turned/repositioned Resident 135 at 0400 hours when he suctioned her, but he did not provide incontinence care. On 11/12/19 at 0721 hours, Resident 135 was observed lying on her left side on a low air loss mattress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 56 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/12/19 at 0800 hours, an ADL care observation for Resident 135 was conducted with CNA 8 and RNA 2. Resident 135 was observed lying on her left side on a low air loss mattress; her position was unchanged from the previous observations (Resident 135 was lying in the same position for four hours since she was last repositioned/turned by Licensed Nurse 11). A dressing to the resident's right elbow was observed saturated with a small amount of blood. When CNA 8 removed Resident 135's incontinence briefs, a strong urine odor was noted. Resident 135's incontinence briefs was observed heavily saturated with yellow urine and a small amount of feces. CNA 8 verified the observations. CNA 8 stated she was going to reposition Resident 135 slightly onto her back because Resident 135's right elbow (where the pressure ulcer was located) would rest directly on the mattress if she was lying on her right side. CNA 8 and RNA 2 completed ADL care (including incontinence care and turning/repositioning) for Resident 135 at 0822 hours. It took two staff members 22 minutes to provide ADL care to one resident. When asked if one CNA could provide incontinence care and turn/reposition 27 residents every two hours and as needed, CNA 8 stated it was not possible. On 11/12/19 at 1032 hours, an interview and concurrent medical record review for Resident 135 was conducted with Licensed Nurse 12. Licensed Nurse 12 stated the elbow was a bony prominence area and the blister could have developed by any combination of pressure, friction, and shearing. Licensed Nurse 12 verified there was no care plan problem developed to address the blood-filled blister to Resident 135's right elbow after it had developed. Licensed Nurse 12 stated Resident 135 was supposed to be turned/repositioned FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 57 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE every two hours and at least two staff members were needed to pull and reposition the resident using sheets to prevent shearing because Resident 135 was heavy and stiff. On 11/12/19 at 1119 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 18. Licensed Nurse 18 verified Resident 135 was noted with a blood-filled blister to the right elbow on 8/16/19, which ruptured and became a Stage 3 pressure ulcer on 8/28/19. Licensed Nurse 18 stated when a blister developed on a bony prominence area it was considered a Stage 2 pressure ulcer and a care plan problem was supposed to be developed to address it. Licensed Nurse 18 verified there were no care plan problems developed to address the right elbow blood-filled blister when it developed or when it had ruptured and became a Stage 3 pressure ulcer. Licensed Nurse 18 stated Resident 135 had bilateral upper extremity contractures, so both of her posterior elbows rested directly on the mattress if she was on her back. Licensed Nurse 18 stated if Resident 135 tensed up, she would press both elbows into the mattress. On 11/12/19 at 1302 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she went through the overflow medical records and found a care plan problem to address Resident 135's right elbow. However, the care plan problem was dated 8/20/18, and addressed a non-pressure ulcer site at the right elbow. The care plan problem was not specific to the blood-filled blister that Resident 135 developed to the right elbow on 8/16/19, which later ruptured and deteriorated into a Stage 3 pressure ulcer on 8/28/19. When asked, the DON stated care plan problems should be developed within 24 hours to address pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 58 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ulcers. The DON also verified a care plan problem was not developed to address Resident 135's pressure ulcer to the right elbow when it deteriorated to Stage 4, until 10/31/19. Review of the Sub-Acute Daily Staffing for August 2019 showed the census ranged from 27 to 29 residents (some days had no documentation to show the day's census). There was only one CNA on duty for the 11 PM to 7 AM shifts on the following dates: 8/5, 8/6, 8/7, 8/8, 8/11, 8/13, 8/14, 8/16, 8/17, 8/18, 8/19, 8/22, 8/24, 8/25, 8/28, 8/29, 8/30, and 8/31/19. On 8/1, 8/12, and 8/15, there were two CNAs scheduled, but the second CNA worked less than 1.93 hours on those days. On 8/23/19, there was one CNA on duty until 0400 hours, when the second CNA started their shift. Resident 135 developed a blood-filled blister to the right elbow on 8/16/19, which ruptured and deteriorated to a Stage 3 pressure ulcer on 8/28/19. for the majority of August 2019, there was only one CNA on duty on the 11 PM to 7 AM shifts prior to Resident 135 developing the blood-filled blister to the right elbow and before it had ruptured. Resident 135 needed to be turned/repositioned every two hours and as needed and required two or more staff members for bed mobility. Cross reference to F725.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/14/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 59 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: 3. Review of the FDA issued safety alert titled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. On 11/7/19 at 0715, 0908, and 1125 hours, Resident 135 was observed lying in bed with bilateral side rails elevated. The right side rail was padded, but the left side rail was not padded. Medical record review for Resident 135 was initiated on 11/7/19. Resident 135 was readmitted to the facility on 3/17/17. Review of the Physician Orders showed an order dated 10/1/18, to have bilateral padded side rails elevated when in bed for positioning and ease of mobility secondary to poor trunk control and seizures. Review of Resident 135's MDSs dated 7/5/19 and 10/24/19, showed Resident 135 was totally dependent on two or more staff members for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 60 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed). Review of the Bed Rail Assessment dated 7/5/19, showed Resident 135 did not have functional mobility. The assessment further showed the side rails were indicated secondary to a diagnosis of seizures. Review of the Physical Therapy Plan of Care dated 8/21/19, showed Resident 135's prior, current, and anticipated level for "Mobility, A. Roll left and right" was dependent. The staff provided all of the effort and the resident provided no effort to complete the activity. On 11/8/19 at 1005 hours, Resident 135 was observed lying in bed with bilateral side rails elevated. The right side rail was padded, but the left side rail was not padded. On 11/8/19 at 1007 hours, an interview was conducted with CNA 8, who was in Resident 135's room. CNA 8 verified Resident 135's left side rail was not padded and stated the padding was in the closet, after she had checked the closet. CNA 8 verified Resident 135 was totally dependent on the staff for ADL care, including bed mobility. When asked, CNA 8 stated Resident 135 could not hold onto the side rails with or without prompting. CNA 8 stated Resident 135 only moved involuntarily, like when she coughed. 2. On 11/8/19 at 0815 hours, Resident 23 was observed in bed with eyes closed and bilateral unpadded 1/2 side rails elevated. Medical record review for Resident 23 was initiated on 11/8/19. Resident 23 was readmitted to the facility on 8/14/19, with diagnoses including quadriplegia (paralysis of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 61 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE all four limbs). Review of Resident 23's MDS dated 10/30/19, showed Resident 23 had a diagnosis of seizure disorder. Review of Resident 23's plan of care showed a care plan problem dated 8/14/19, addressing the potential for injury due to seizure disorder. Interventions included to provide padded side rails. On 11/8/19 at 1650 hours, an observation, interview, and concurrent medical record review was conducted with Licensed Nurse 1. Licensed Nurse 1 verified Resident 23 had bilateral unpadded side rails elevated. Licensed Nurse 1 stated maybe Resident 23 had the rails elevated due to seizures. Licensed Nurse 1 did not know when Resident 23 had experienced seizures. Licensed Nurse 1 verified Resident 23's plan of care showed to provide padded side rails. Cross reference to

F700, example #4.Based on observation, interview, and medical record review the facility failed to ensure three of 34 final sampled residents (Residents 122, 23, and 135) remained free from accident hazards. * The facility failed to implement fall mats for Resident 122 as per the physician's order and as care planned for Resident 122's behavior of spontaneous movement from the bed to the floor. * The facility failed to follow an intervention as documented in Resident 23's plan of care for the use of padded side rails due to seizure disorder. Resident 23 was observed in bed with unpadded bilateral side rails elevated. * The facility implemented bilateral side rails for Resident 135 to promote bed mobility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 62 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE However, Resident 135 was totally dependent on the staff for bed mobility and had a history of seizures. In addition, the facility failed to ensure both side rails were padded as ordered by the physician. These failures posed the risk for Resident 135 to become entrapped or injured by the side rails. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Medical record review for Resident 122 was initiated on 11/7/19. Resident 122 was readmitted to the facility on 7/13/15. Review of the physician's order dated 10/11/18, showed an order for floor mats to decrease potential injury from spontaneous movement from bed to the floor mat. Review of a care plan problem titled At Risk for Falls and Injuries, secondary to visual problems and poor safety judgement dated 10/2019, showed Resident 122 had episodes of preferring to sit on the floor due to cultural background. On 11/7/19 at 1415 hours, an observation was conducted of Resident 122. Resident 122 was observed lying in bed, asleep. No floor mats were observed on the floor adjacent to Resident 122's bed. On 11/7/19 at 1418 hours, an observation and concurrent interview was conducted with CNA 11. CNA 11 verified Resident 122 did not have floor mats on the floor adjacent to Resident 122's bed. On 11/12/19 at 0722 hours, an observation and concurrent interview was conducted with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 63 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Nurse 16. Resident 122 was observed lying in bed, asleep. No floor mats were observed on the floor adjacent to Resident 122's bed. Licensed Nurse 16 verified the finding.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 02/06/2020 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 64 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTIs for one of 34 final sampled residents (Resident 45) with an indwelling urinary catheter. Resident 45 had a history of recurrent UTIs. * The staff failed to ensure proper positioning of Resident 45's urinary drainage bag to prevent urine from flowing back into the bladder. This posed the risk for Resident 45 to develop a catheter-associated urinary tract infection (CAUTI). Findings: Review of the Centers for Disease Control and Prevention's (CDC) article (undated) titled Catheter-Associated Urinary Tract Infection showed a UTI is an infection in the urinary tract system (including the bladder and the kidneys). Germs can travel along the catheter, and if they enter the urinary tract, may cause an infection in the bladder or kidneys. Prevention of CA-UTIs include keeping the urinary drainage bag lower than the bladder to prevent urine from back-flowing to the bladder. On 11/7/19 at 0723 hours, during the initial tour of the facility, Resident 45 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag. The urinary drainage bag was observed resting on the bed. On 11/7/19 at 0729 hours, CNA 4 was asked to come to Resident 45's room. CNA 4 verified the urinary drainage bag should not be placed on the bed and should be attached to the bed frame, below the resident. CNA 4 stated the night shift staff probably left the urinary drainage bag on the bed. CNA 4 left the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 65 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's room without placing the urinary drainage bag below the level of the resident's bladder. The urinary drainage bag was still resting on the bed. On 11/7/19 at 0749 hours, Resident 45 was observed in bed with the urinary drainage bag still resting on the bed. Medical record review for Resident 45 was initiated on 11/7/19. Resident 45 was readmitted to the facility on 9/22/19. Review of the general acute care hospital's documentation dated 9/18/19, showed Resident 45 had a history of recurrent UTIs. On 11/8/19 at 0812 hours, an interview was conducted with the DON. The DON stated when a care concern relating to the resident is brought to the attention of the staff, the staff should address it right away if it was within their scope. The DON verified the urinary drainage bag should be placed below the level of the bladder to prevent infections. Cross reference to F656, example #4.

F694 SS=D Parenteral/IV Fluids CFR(s): 483.25(h)

F694 02/06/2020 § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 34 final sampled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 66 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents (Residents 126 and 348) received appropriate care regarding a PICC and IV catheters. * The facility failed to ensure Resident 126's PICC was assessed on admission and ongoing and care was provided and documented. * The facility failed to ensure appropriate care was provided to resident 348's peripheral IV site. These posed the risk of Residents 126 and 348 developing complications related to the use of the PICC and IV catheters. Findings: Review of the facility's P&P titled Catheter Insertion and Care-Central Venous Catheter Dressing Changes revised in July 2013 showed the following information should be recorded in the resident's medical record: - Date and times the dressing was changed. - Location and objective description of the insertion site. - Any complications, interventions that were done. - Whether flushed or positive blood return. - Type of dressing placed. - Any questions, education given to resident, resident's statement regarding IV therapy and response to procedure. - Signature and title of the person recording the data. 1. On 11/7/19 at 1444 hours, Resident 126 stated she had some discomfort at her PICC site. Resident 126's PICC was observed on her left upper arm. The PICC dressing dated 11/1/19, was observed with dried blood through a transparent dressing over the PICC site. Resident 126 stated she was admitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 67 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility with the PICC and she reported bleeding and pain around the PICC site to the nurse on the admission date. The nurse changed the PICC dressing and inserted a peripheral IV on the admission day. Resident 126 stated she did not know the reason why the facility had not used the PICC, but inserted a peripheral IV. On 11/8/19 at 0807 hours, an interview was conducted with Licensed Nurse 4. Licensed Nurse 4 was asked about Resident 126's PICC. Licensed Nurse 4 stated Resident 126 did not have a PICC, but had a peripheral IV. Licensed Nurse 4 stated she was not aware of Resident 126's PICC; the IV nurse was the one who assessed and documented any lV or PICC care. On 11/8/19 at 0812 hours, an interview was conducted with Licensed Nurse 5. Licensed Nurse 5 was asked about PICC care. Licensed Nurse 5 stated the dressing needed to be changed weekly, flush the catheter daily if not in use, if the PICC was being used, flush the catheter before and after the administering medications. Also assess the site for any signs of infection and document the care on the IV sheet. Licensed Nurse 5 was asked if Resident 126's PICC was assessed and the care was provided. Licensed Nurse 5 stated she was not aware of Resident 126 had a PICC. Licensed Nurse 5 stated Resident 126 had a peripheral IV on her right hand and she had been using only the peripheral IV. On 11/8/19 at 1054 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 5. Review of the Admission Assessment dated 11/1/19, failed to show documentation of the PICC upon admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 68 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Nurses Notes from 11/1/19 to 11/7/19, failed to show documentation of ongoing assessments and care for the PICC. Review of Licensed Nurses' Daily Skilled Charting from 11/2/19 to 11/7/19, only showed documentation of the peripheral IV, but no documentation of the PICC. Review of the Intravenous Therapy Medication Record showed the right hand IV was started on 11/1/19, but no documentation of the PICC. Licensed Nurse 5 verified the nurses were not aware of Resident 126's PICC and did not assess the PICC site and did not provide necessary care to the PICC since admission. 2. On 11/7/19 at 0832 hours, Resident 348 was observed sitting at the edge of his bed. A peripheral intravenous (IV) line was observed at Resident 348's left arm, covered by a transparent dressing. The dressing was observed to be filled with dried blood around the IV site. The dressing was not dated. Resident 348 stated he had been in the facility for three or four days and the IV line was inserted at the general acute care hospital way before he was admitted to the facility. Resident 348 stated the IV site was leaking that was why there was a lot of blood. On 11/7/19 at 0920 hours, Licensed Nurse 13 was called to the room and verified the above findings. Licensed Nurse 13 stated she could not tell how long ago the IV was inserted because it was not dated. Licensed Nurse stated the IV needed to be changed. Medical record review for Resident 348 was initiated on 11/7/19. Resident 348 was admitted to the facility on 11/4/19. Review of the IV Therapy Orders dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 69 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/4/19, showed IV site change every 72 hours and PRN (as needed) for redness, edema, drainage or infiltration. Dressing and cap change every seven days and PRN if soiled, wet or loose. On 11/7/19 at 0918 hours, a follow-up interview and concurrent medical record review was conducted with Licensed Nurse 13. Licensed Nurse 13 reviewed the medical record and acknowledged the above findings.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 12/14/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide respiratory care to meet the needs of two of 34 final sampled residents (Residents 67 and 1). * The facility failed to follow the physician's order to place Resident 67 on the ventilator settings intended to wean the resident from the mechanical ventilator. This had the potential for a delay in weaning the resident from the mechanical ventilator. * The facility failed to ensure the physician's order to administer PRN oxygen to Resident 1 included the parameters for its use. The facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 70 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE failed to follow the physician's order to monitor Resident 1's oxygen saturation (the amount of oxygen in the blood) every shift. These failures posed the risk of the resident receiving unnecessary oxygen. Findings: 1. On 11/7/19 at 0715 and 0932 hours, Resident 67 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator. The ventilator settings were AC mode, rate of 16, tidal volume 400, and PEEP of 5. Resident 67's respirations were even and unlabored and Resident 67 had no signs or symptoms of respiratory distress. Medical record review for Resident 67 was initiated on 11/7/19. Resident 67 was readmitted to the facility on 8/30/19. Review of the Physician Orders showed an order dated 8/30/19, showing to place Resident 67 on the following ventilator settings: AC mode, rate of 16, tidal volume 400, and PEEP of 5. Review of the Physician Orders showed an order dated 10/15/19, showing to place Resident 67 on the following ventilator settings as tolerated: SIMV mode, rate of 12, tidal volume 400, PEEP of 5, and pressure support of 12. On 11/7/19 at 1128, 1243, and 1434 hours, Resident 67 was observed connected to the mechanical ventilator on the following ventilator settings: AC mode, rate of 16, tidal volume 400, and PEEP of 5. On 11/8/19 at 0721 and 0920 hours, Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 71 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 67 was observed connected to the mechanical ventilator on the following ventilator settings: SIMV mode, rate of 12, tidal volume 400, PEEP of 5, and pressure support of 12. Resident 67's respirations were even and unlabored and Resident 67 had no signs or symptoms of respiratory distress. On 11/8/19 at 1101 hours, an interview and concurrent medical record review was conducted with RT 2. RT 2 verified how to check the ventilator settings. RT 2 verified Resident 67 had a physician's order to be placed on SIMV mode, rate of 12, tidal volume 400, PEEP of 5, and pressure support of 12 as tolerated, to wean the resident off the mechanical ventilator. RT 2 stated if the resident did not tolerate the weaning settings, the RTs were supposed to place Resident 67 on AC mode, rate of 16, tidal volume 400, and PEEP of 5. RT 2 stated Resident 67 should have been placed on the weaning settings unless she was in respiratory distress (such as labored breathing, shortness of breath, increased respirations). RT 2 verified all ventilator setting changes were supposed to be documented. RT 2 verified there was no documentation to show Resident 67 was in respiratory distress and was placed on the AC mode, on 11/7/19. RT 2 verified the Continuous Ventilator Flow Sheets dated 10/24/19 to 11/6/19, showed Resident 67 tolerated the weaning settings (SIMV mode, rate of 12, tidal volume 400, PEEP of 5, and pressure support of 12) well and had no respiratory distress. On 11/8/19 at 1111 hours, a telephone interview was conducted with RT 3. RT 3 verified Resident 67's ventilator settings on 11/7/19, was AC mode, rate of 16, tidal volume 400, and PEEP of 5. RT 3 stated he placed Resident 67 on the AC mode in the morning FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 72 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE because she was having labored breathing. RT 3 verified there was no documentation to show Resident 67 had labored breathing or was in respiratory distress and was placed on the AC mode. RT 3 acknowledged the resident's condition and any ventilator setting changes had to be documented. On 11/8/19 at 1218 hours, an interview was conducted with RT 4. RT 4 stated Resident 67 was received on the ventilator weaning settings and had been tolerating the settings well. RT 4 stated Resident 67 was stable and had no labored breathing, shortness of breath, or respiratory distress. 2. On 11/7/19 at 1126 hours, Resident 1 was observed lying in bed, receiving oxygen at 4 liters per minute through a nasal cannula (thin flexible tube with small prongs inserted into the nostrils). Medical record review for Resident 1 was initiated on 11/7/19. Resident 1 was readmitted to the facility on 10/7/19. Review of the Physician Orders showed an order dated 10/22/19, to administer oxygen at 4 liters per minute via nasal cannula PRN for shortness of breath; and to monitor the oxygen saturation every shift for shortness of breath. However, there was no parameter when to administer the PRN oxygen. Review of the Medication Record for November 1019 showed the oxygen saturation was scheduled to be monitored daily on the 0700 to 1500, 1500 to 2300, and 2300 to 0700 hours shifts. However, the licensed nurses were not consistently documenting what Resident 1's oxygen saturation levels were every shift. On 11/12/19 at 0742 hours, an interview and concurrent medical record review was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 73 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with Licensed Nurse 15. Licensed Nurse 15 verified the above findings and stated they monitored Resident 1's oxygen saturation, and if it was low, the PRN oxygen was administered. Licensed Nurse 15 stated her interpretation of a low oxygen saturation would be 95%, however, there was no parameter identified in the physician's order. Licensed Nurse 15 failed to show documentation the oxygen saturation of Resident 1 was accurately documented every shift as ordered by the physician.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 12/14/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide appropriate pain management for one of 34 final sampled residents (Resident 100). * The facility failed to ensure Resident 100 was administered her pain medication promptly after she experienced severe pain. The facility failed to provide appropriate pain medication to the pain level Resident 100 was experiencing as prescribed by the physician for approximately 24 hours due to unavailability of the medication. The Licensed Nurses failed to notify the physician nor contact the pharmacy to dispense the pain medication which was available in the facility's Automated Drug Dispensing System. These failures resulted in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 74 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 100's severe pain left unmanaged and Resident 100 feeling fearful and helpless because she was not receiving her pain medication to manage her severe pain. Findings: On 11/7/19 at 1031 hours, an interview was conducted with Resident 100. Resident 100 stated she preferred to stay in bed because she was always in pain. Resident 100 stated she pressed her call light whenever she needed her pain medication. Resident 100 stated yesterday (11/6/19), she had to wait for almost two hours to be administered her pain medication when she experienced a pain level of 8 out of 10 (on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain). Resident 100 stated she asked for her pain medication at 1200 hours and was not administered the medication until 1350 hours. Medical record review for Resident 100 was initiated on 10/7/19. Resident 100 was admitted to the facility on 6/25/19. Review of the History and Physical Examination dated 6/26/19, showed Resident 100 had diagnoses including severe leg weakness and pain secondary to severe osteoarthritis of the knees. Review of the Quarterly MDS dated 10/2/19, showed Resident 100 had no cognitive impairment. Review of the Pain Reassessment dated 7/3/19, showed Resident 100 was reassessed for pain due to increased generalized body pain. Resident 100 experienced throbbing pain almost constantly. Resident 100's physician was informed and increased the dose of her PRN Norco (narcotic pain medication) for pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 75 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Physician Orders showed an order dated 7/3/19, to administer Norco 5/325 mg two tablets by mouth every six hours PRN for pain management and an order dated 6/25/19, to monitor every shift for pain using the pain intensity scale from 0 to 10 with 0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, and 10 = very severe pain. Review of the Pain Assessment Flow Sheets and Medication Records for September, October, and November 2019 showed Resident 100 had been assessed to have severe pain (8 out of 10) almost every shift and requested the PRN Norco every six hours. Review of the Medication Record for November 2019 showed Resident 100 was assessed to have a pain level of 8 during the 0700 to 1500 hours shift on 11/6/19. However, there was no documentation to show Resident 100 was administered the Norco tablets to manage her pain. Review of the Drug Control Receipt/Record/Disposition Form for the Norco tablets showed two tablets of Norco were signed out on 11/6/19 at 1300 hours. On 11/12/19 at 0655 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 7. Licensed Nurse 7 reviewed the medical record and verified the above finding. Licensed Nurse 7 stated Resident 100 was constantly complaining of pain " ...all over," and during the 2300 to 0700 hours shift, she observed Resident 100 could not sleep because of pain. On 11/13/19 at 1045 hours, Resident 100 was observed lying in bed with facial grimacing. When asked how she was, Resident 100 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 76 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she was in pain and she "...ran out" of her pain medication. Resident 100 stated she was last administered the Norco tablets for pain yesterday (11/12/19) at 1200 hours. Afterwards, she was told by the licensed nurses she did not have any available Norco tablets for pain. Resident 100 stated they offered her Tylenol, but she refused because the Tylenol made her feel sick. Resident 100 stated she had a pain level of 6 at this time and "... as hours go by, it escalates. I'm lying here. When you're stuck in bed, it's pretty hard." Resident 100 stated she did not understand why she ran out of pain medication and the licensed nurses could not tell her when her pain medication would become available. Resident 100 stated she ran out of the pain medication two months ago for five days and was afraid this would happen again. Resident 100 stated, "...I guess I will have to lay here in pain." Review of the Physician Orders failed to show an order for Tylenol to be administered to Resident 100 for pain. Review of the Medication Record for November 2019 showed the monitoring for pain every shift as follows: - On 11/12/19, during the 1500 to 2300 hours shift: no entry (blank) - On 11/12/19, during the 2300 to 0700 shift: pain level of 8 - On 11/13/19, during the 0700 to 1500 hours shift: pain level of 8. Further review of the Medication Record showed Resident 100 was last administered the Norco tablets for pain on 11/12/19 at 0600 hours. An entry on 11/13/19 at 0530 hours, showed Resident 100 complained of 6/10 pain. Resident 100 requested to be administered the Norco tablets for her pain. Resident 100 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 77 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE offered Tylenol but refused. There was no documentation to show what was done to manage Resident 100's pain. Review of the Nurses Notes showed an entry dated 11/13/19 at 0400 hours, regarding Resident 100 requesting the Norco tablets for pain. The entry showed the licensed nurse called the pharmacy at 0030 hours and was told they were awaiting the "MD Continuation Form." Resident 100 was made aware and understood why her Norco tablet was not available. The note failed to show how Resident 100's pain was managed nor if Resident 100's physician was notified of the unavailability of the pain medication to manage Resident 100's pain. On 11/13/19 at 1053 hours, an interview was conducted with Licensed Nurse 3. Licensed Nurse 3 verified Resident 100 was out of her Norco tablets for pain since yesterday because the pharmacy had not sent the refill. Licensed Nurse 3 stated they should have requested for a refill of the Norco 5-7 days before it was due. Licensed Nurse 3 stated she thought the medication refill was requested because the reorder label was already taken off. Licensed Nurse 3 stated the pharmacy was waiting for the physician's signature because the refill was only requested yesterday. Licensed Nurse 3 stated she was aware Resident 100 complained of pain and she offered Resident 100 Tylenol, but the resident refused. Licensed Nurse 3 verified Resident 100 was not administered pain medication even though Resident 100 was constantly complaining of pain. When asked if the facility had an emergency kit, Licensed Nurse 3 stated yes, but she did not think there was available Norco in the emergency kit. When asked if she had checked the emergency kit for the availability of the Norco, Licensed Nurse 3 stated no. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 78 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Nurse 3 could not provide documentation the physician was informed of Resident 100's pain and the unavailability of her Norco tablets. Review of the list of medications available in the facility's Automated Drug Dispensing System showed Norco 5/325 mg and 10/325 mg tablets were available. On 11/13/19 at 1132 hours, an interview was conducted with Licensed Nurse 6. Licensed Nurse 6 stated the facility's Automated Drug Dispensing System was used for emergencies. Licensed Nurse 6 verified the Norco tablets were available in the Automated Drug Dispensing System. On 11/13/19 at 1204 hours, an interview was conducted with CNA 7. CNA 7 stated when she checked Resident 100 at approximately 0730 hours at the start of her shift, she found Resident 100 crying because of pain. CNA 7 stated Resident 100 told her the licensed nurses said she did not have any pain medication and did not understand why. CNA 7 stated Resident 100 refused a bed bath and did not want to be changed. When asked what she did after, CNA 7 stated she told Resident 100 not to cry and informed the licensed nurse about this. On 11/13/19 at 1539 hours, the DON was informed and acknowledged the above findings. Cross reference to F755, example #1.

F700 SS=D Bedrails CFR(s): 483.25(n)(1)-(4)

F700 12/14/2019 §483.25(n) Bed Rails. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 79 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure six of 34 final sampled residents (Residents 83, 100, 699, 23, 142, and 589) remained free from accident hazards due to the use of elevated side rails. * The facility failed to ensure Residents 23, 83, 100, 142, 589, and 699 were assessed for risks of entrapment from side rails, informed consent was obtained from the residents' representatives, risks and benefits were explained, and least restrictive alternatives were attempted prior to the use of bilateral side rails, and side rails were included in the plan of care. These failures had the potential to put residents at risk of entrapment and serious injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 80 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed side rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, or acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Review of the facility's P&P titled Proper Use of Bed Rails (undated) showed an assessment will be made to determine whether to use bed rails to meet the needs of the resident. Alternative measure attempts prior to the use of bed rails will be documented along with the reason why the measures were ineffective. The risks and benefits will be explained to the resident or responsible party, and informed consent will be obtained from the resident or responsible party. The use of bed rails, medical necessity, risks involved, and alternatives tried prior to the use of bed rails will be documented in the resident's plan of care. 1. On 11/7/19 at 1007 hours, Resident 83 was observed lying in bed with bilateral side rails (located at the middle of the bed) elevated. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19, and readmitted on 10/29/19. Review of the Admission MDS dated 9/25/19, showed Resident 83 had severe cognitive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 81 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE impairment. Review of the medical record failed to show documentation Resident 83 was assessed for the risk of entrapment with the use of side rails, informed consent was obtained from Resident 83's representative, risks and benefits were explained, and least restrictive alternative was attempted prior to the use of bilateral side rails. Review of the plan of care failed to show a care plan problem was developed to address the use of the side rails. On 11/8/19 at 0930 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 13. Licensed Nurse 13 verified Resident 83 had bilateral side rails and there was no documentation to show Resident 83 was assessed for the risk of entrapment with the use side rails, informed consent was obtained from Resident 83's representative, risks and benefits were explained, and least restrictive alternatives were attempted prior to the use of bilateral side rails. Licensed Nurse 13 verified the use of side rails was not documented in Resident 83's plan of care. 2. On 11/7/19 at 1031 hours, an interview was conducted with Resident 100 in her room. Resident 100 was observed lying in bed with bilateral side rails (located by the head of the bed) elevated. When asked if she used the side rails, Resident 100 stated no, she did not need the side rails because she had not fallen out of bed. Review of the Quarterly MDS dated 10/2/19, showed Resident 100 had no cognitive impairment. Review of the medical record failed to show FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 82 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documentation Resident 100 was assessed for the risk of entrapment from the side rails, if informed consent was obtained from Resident 100 or her representative, risks and benefits were explained, and least restrictive alternatives were attempted prior to the use of bilateral side rails. On 11/12/19 at 0709 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 7. Licensed Nurse 7 verified Resident 100 had bilateral side rails elevated, however, failed to show documentation Resident 100 was assessed for the risk of entrapment from the side rails, informed consent was obtained from Resident 100 or her representative, the risks and benefits were explained, and least restrictive alternatives were attempted prior to the use of bilateral side rails. 5. On 11/7/19 at 0814 hours, Resident 142 was observed in bed with the left side rail elevated. On 11/7/19 at 0900 hours, 11/8/19 at 1241 hours, and 11/12/19 at 0706 and 0826 hours, Resident 142 was observed in bed with bilateral side rails elevated. Medical record review for Resident 142 was initiated on 11/8/19. Resident 142 was admitted to the facility on 10/11/19. Review of Resident 142's MDS dated 10/18/19, showed Resident 142 had severe cognitive impairment and requiring extensive assistance from one person for bed mobility and transferring. On 11/12/19 at 0836 hours, an interview was conducted with CNA 5. CNA 5 was asked if Resident 142's side rails were always elevated. CNA 5 stated Resident 142's side rails were always up. CNA 5 stated sometimes she put only the right side rail up, but usually both side FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 83 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rails were up for fall prevention. Review of the Bed Rail Assessment for Resident 142 showed no documentation regarding the type of side rail used, the indications for use, alternatives attempted, and the reason why the alternatives were not effective. On 11/12/19 at 0838 hours, an interview and concurrent medical record review for Resident 142 was conducted with the DON. The DON verified necessary assessments prior to the use of side rails were not performed for Resident 142. 6. On 11/7/19 at 1218 hours, 11/8/19 at 0857 hours, and at 1127 hours, Resident 598 was observed in bed with bilateral side rails elevated. On 11/7/19 at 1218 hours, an interview was conducted with Family member B. Family member B was asked when Resident 598 started using the side rails. Family member B stated she visited Resident 598 every day and staff had been using the side rails since admission. Family member B was asked if staff explained the risks and benefits associated the use of side rails. Family member B stated she was not sure about the risks and benefits but she was told the reason for the use of the side rails was for prevent falls. Review of the medical record for Resident 598 was initiated on 11/7/19. Resident 598 was admitted to the facility on 10/30/19. Review of Resident 598's MDS dated 11/7/19, showed Resident 598 had moderate cognitive impairment and required extensive assistance from one person for bed mobility and transfers. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 84 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Bed Rail Assessment for Resident 598 showed no documentation regarding the type of side rail to be uses, the indications for use, alternative attempts, and the reason why the alternatives were not effective. On 11/8/19 at 1135 hours, an interview and concurrent medical record review for Resident 598 was conducted with Licensed Nurse 5. Licensed Nurse 5 verified the Bed Rail Assessment was blank and stated the facility should have assessed for the use of side rails before using the side rails. On 11/12/19 at 0838 hours, an interview and concurrent medical record review for Resident 598 was conducted with the DON. The DON verified the necessary assessments prior to the use of side rails were not performed for Resident 598. 3. Medical record review for Resident 699 was initiated on 11/7/19. Resident 699 was readmitted to the facility on 10/31/19. Review of Resident 699's MDS dated 10/4/19, showed Resident 699 had severely impaired cognition and had bilateral hand contractures. The MDS also showed Resident 699 was totally dependent on two or more persons for bed mobility. Review of Resident 699's Bed Rail Assessment signed by two IDT members, one being the RD dated 11/6/19, and the other signature illegible and dated 11/10/17, showed under IDT recommendation: indication for use: "Bed Rail/Transfer Bar are indicated and resident demonstrates ability to use equipment as an enabler." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 85 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 699's undated care plan titled Fall Reduction Related To Risk for Falls, showed Resident 699 had poor safety awareness and judgement. Review of Resident 699's care plan titled Occupational Therapy Treatment dated 11/1/19, showed Resident 699 had bilateral upper extremity contractures with decreased upper extremity strength and coordination. On 11/7/19 at 0833 hours, an observation of Resident 699 was conducted. Resident 699 was observed lying in bed with bilateral side rails elevated at the middle of the bed. Review of Resident 699's Restrictive Measures - Risk/Benefits form (undated) showed the form contained generic verbiage. At the bottom of the form under, "The above risks and benefits were explained to me and I understand the need and.." "I agree" was checked. However, where the resident/representative was to sign and date the form was blank. On 11/7/19 at 0917 hours, an interview was conducted with Licensed Nurse 13. Licensed Nurse 13 stated if side rails were to be used on a resident's bed, the facility was to first attempt alternatives to the use of side rails, then conduct an entrapment assessment, and obtain informed consent. On 11/7/19 at 0922 hours, an observation, interview, and medical record review was conducted with Licensed Nurse 13. Resident 699 was observed lying in bed with bilateral side rails elevated at the middle of the bed. Licensed Nurse 13 reviewed Resident 699's medical record and verified consent had not been obtained for the use of elevated side rails. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 86 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/12/19 at 1320 hours, an interview was conducted with CNA 10. CNA 10 stated he was assigned to and cared for Resident 699 on 11/7/19. CNA 10 stated Resident 699 had upper extremity contractures and did not utilize the side rails. 4. On 11/8/19 at 0815 hours, Resident 23 was observed in bed with eyes closed and bilateral, unpadded, 1/2 side rails elevated. Medical record review for Resident 23 was initiated on 11/8/19. Resident 23 was readmitted to the facility on 8/14/19, with diagnoses including quadriplegia (paralysis of all four limbs). Review of Resident 23's MDS dated 10/30/19, showed Resident 23 had severe cognitive impairment, was totally dependent on staff, and required two persons assistance for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). On 11/8/19 at 1650 hours, an observation, interview, and concurrent medical record review was conducted with Licensed Nurse 1. Licensed Nurse 1 was asked about Resident 23. Licensed Nurse 1 stated Resident 23 did not move any extremities, nor did he use the side rails. Licensed Nurse 1 verified Resident 23 had bilateral unpadded side rails elevated. Licensed Nurse 1 stated maybe Resident 23 had the rails elevated due to seizures. Licensed Nurse 1 stated an order was needed for side rails, as well as consent, and an assessment. Licensed Nurse 1 reviewed Resident 23's medical record and was unable to find an order nor an assessment for the use of Resident 23's side rails. Review of Resident 23's Facility Verification of Informed Consent showed a check box for prolonged use of padded one quarter side rails, however there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 87 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was no date. There was no documentation to show the risks and benefits of side rails were addressed/discussed with Resident 23's legal representative.

F725 SS=E Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2)

F725 12/14/2019 §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. This REQUIREMENT is not met as evidenced by: 2. On 11/7/19 at 0952 hours, an interview was conducted with Resident 57. Resident 57 stated there was usually only one CNA on duty on the 2300 to 0700 hours shifts. When asked how she knew there was only one CNA on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 88 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE those shifts, Resident 57 stated because the staff told her that was the reason she had to wait longer for help when she called. Resident 57 stated sometimes the 3 PM to 11 PM shifts only had one CNA as well. Resident 57 stated she complained to the Administrator about the lack of staffing in the subacute unit and her family member had complained to the Administrator as well, but was told by the Administrator that the facility had enough staffing. Resident 57 stated she just wanted to be provided the assistance she needed and was tired of hearing excuses. Review of the Sub-Acute Daily Staffing for July 2019 showed the census ranged from 24 to 29 residents. There was only one CNA on duty for the 2300 to 0700 hours shifts on the following dates: 7/3, 7/5, 7/6, 7/8, 7/9, 7/14, 7/15, 7/18, 7/20, 7/21, 7/26, 7/27, and 7/30/19. On 7/7, 7/13, 7/19, and 7/25/19, there were two CNAs scheduled, but the second CNA worked less than 1.45 hours on those days. Only one CNA was on duty to turn/reposition and provide incontinence care every two hours and as needed for 24 to 29 residents. Review of the Sub-Acute Daily Staffing for August 2019 showed the census ranged from 27 to 29 residents (some days had no documentation to show the day's census). There was only one CNA on duty for the 2300 to 0700 hours shifts on the following dates: 8/5, 8/6, 8/7, 8/8, 8/11, 8/13, 8/14, 8/16, 8/17, 8/18, 8/19, 8/22, 8/24, 8/25, 8/28, 8/29, 8/30, and 8/31/19. On 8/1, 8/12, and 8/15, there were two CNAs scheduled, but the second CNA worked less than 1.93 hours on those days. On 8/23/19, there was one CNA on duty until 0400 hours, when the second CNA started their shift. There was consistently only one CNA on duty on the 2300 to 0700 hours shifts to turn/reposition and provide incontinence care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 89 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE every two hours and as needed for 27 to 29 residents. On 11/12/19 at 0509 hours, a white board displaying the subacute unit's staff assignment was observed on the wall across from the nurses' station. The white board showed there was one CNA on duty for the 2300 to 0700 hours shift. On 11/12/19 at 0517 hours, an interview was conducted with CNA 3. CNA 3 stated his shifts were 7.5 hours and he was the only CNA on duty. CNA 3 stated he was assigned to provide care to 27 residents. When asked what his duties included, CNA 3 stated he was supposed to provide incontinence care and turn/reposition the residents at least every two hours. When asked how long it took him to provide care to one resident, CNA 3 stated it took him approximately 20 to 30 minutes to provide care to one resident (it would take nine hours for CNA 3 to provide care to 27 residents once, if each resident required 20 minutes). CNA 3 stated it was pretty hard providing care to 27 residents by himself. When asked if the licensed nurses provided ADL care to the residents, CNA 3 stated the nurses could not always provide ADL care to the residents or help him because they were busy with their own work. CNA 3 stated he started his shifts by providing care to the first resident and worked his way through to the last resident. CNA 3 stated he would then start the process over, if he had time. CNA 3 stated he had to sometimes skip his breaks and lunches to finish his work. CNA 3 stated there were only two CNAs on staff for the 2300 to 0700 hours shift. CNA 3 stated there were about four days a week where there is only one CNA on duty for the 2300 to 0700 hours shift. When asked if the management was aware about the CNA staffing, CNA 3 stated yes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 90 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/12/19 at 0536 hours, an interview was conducted with Licensed Nurse 9. Licensed Nurse 9 stated there was supposed to be at least two CNAs on duty during the night shift, but there was only two CNAs on staff for the night shift. Licensed Nurse 9 stated that was why there was only one CNA working on some of the night shifts. Licensed Nurse 9 stated the unit's average census was around 27 and CNA staffing for the night shift had been a problem since at least July. When asked, Licensed Nurse 9 stated she did not think one CNA could adequately care for 27 residents. Licensed Nurse 9 stated the residents needed to be checked, cleaned, and turned every two hours and as needed. Licensed Nurse 9 acknowledged the residents were not being provided with incontinence care and were not being turned/repositioned every two hours because they were short staffed. Licensed Nurse 9 stated the nurses could not always provide ADL care to the residents because they had to complete their own work. On 11/12/19 at 0657 hours, an interview was conducted with Licensed Nurse 11. Licensed Nurse 11 was asked what ADL care the residents required. Licensed Nurse 11 stated the residents were supposed to be checked to see if they required incontinence care every two hours and were supposed to be turned every two hours to prevent pressure ulcers. When asked if one CNA could provide adequate care to 27 residents, Licensed Nurse 11 stated "hell no." Licensed Nurse 11 stated he felt bad for the CNAs so he would help sometimes, but he also needed to make sure he finished his own work. Licensed Nurse 11 stated when he helped the CNAs, it took him 30 minutes to clean and turn/reposition one "easy" resident. Licensed Nurse 11 acknowledged the residents were not being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 91 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cleaned and turned every two hours. On 11/12/19 at 0726 hours, an interview was conducted with CNA 8. CNA 8 stated, at the start of her shift, she would first check her assignment, fill her linen cart, and obtain the residents' vital signs before providing ADL care. On 11/12/19 at 0800 hours, an ADL care observation for Resident 135 was conducted with CNA 8 and RNA 2. When CNA 8 removed Resident 135's incontinence brief, a strong urine odor was noted. Resident 135's incontinence brief was observed heavily saturated with yellow urine and a small amount of feces. CNA 8 verified the observations. CNA 8 and RNA 2 completed ADL care (including incontinence care and turning/repositioning) for Resident 135 at 0822 hours. It took two staff members 22 minutes to provide ADL care to one resident. When asked if one CNA could provide incontinence care and turn/reposition 27 residents every two hours and as needed, CNA 8 stated it was not possible. On 11/12/19 at 0830 hours, an observation of Resident 73 was conducted with CNA 8. CNA 8 turned Resident 73 to check if Resident 73 had a bowel movement. Resident 73 was observed lying in a large amount of soft feces. Resident 73's sacrococcyx pressure ulcer was observed with no dressing in place and the wound was observed covered with feces. CNA 8 verified the findings. On 11/12/19 at 0837 hours, an interview was conducted with Licensed Nurse 12. When asked if one CNA could provide adequate care to 27 residents, Licensed Nurse 12 stated there was no way one CNA could adequately care for 27 residents because the residents needed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 92 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE be provided incontinence care and turned/repositioned every two hours. On 11/12/19 at 0843 hours, an interview was conducted with Licensed Nurse 18. When asked about the CNA staffing for the 2300 to 0700 hours shift, Licensed Nurse 18 stated most of the nights there was only one CNA on duty. Licensed Nurse 18 stated the unit had been short-staffed for a few months. When asked if one CNA could provide safe and quality care to 27 residents, Licensed Nurse 18 stated no, one CNA could not provide care to the residents every two hours and as needed like they were supposed to. On 11/13/19 at 0631 hours, an interview was conducted with CNA 9. CNA 9 was asked about the CNA staffing for the 2300 to 0700 hours shift. CNA 9 stated the staffing was not good for the residents because there were several days a week where there would be only one CNA on duty for the subacute unit. CNA 9 stated the residents were supposed to be provided incontinence care and were supposed to be turned/repositioned every two hours. CNA 9 stated it took him approximately 15 to 20 minutes to provide care to one resident (it would take 6.75 hours for CNA 9 to provide care to 27 residents once, if each resident required 15 minutes). CNA 9 stated he was only able to provide care to the residents once on his shift. Based on observation, interview, medical record review, and facility document review, the facility failed to ensure adequate 24 hour staffing was maintained to meet the physical and psychosocial needs of the residents when one CNA was assigned to care for 27 residents on the subacute unit on multiple occasions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 93 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This failure resulted in the residents not being provided with care consistent with professional standards of practice and care as outlined in their person centered plans of care. Cross references to F550, example #1; F686; F755, examples #10, 11, 12, and 13; and F838). Findings: 1. Review of the CMS Form 671 signed by the Administrator on 11/7/19, showed the facility had 31 subacute beds (for residents requiring ventilator/respiratory care). Review of the facility's Nursing Staffing Assignment and Sign-in Sheet for the subacute unit showed only one CNA was scheduled for the entire unit on multiple occasions. For example: - On 10/26 and 10/27/19, one CNA was scheduled for the 1500 to 2300 hours shift. A second CNA worked until 1600 hours. - On 10/28, 10/30, 10/31/19, 11/2, and 11/3/19, one CNA was scheduled for the 2300 to 0700 hours shift. On 11/12/19 at 0515 hours, an interview and concurrent facility document review was conducted with Licensed Nurse 9. Licensed Nurse 9 stated the census for the subacute unit was 27, with 21 of those residents being in contact isolation requiring donning and doffing of PPE and sanitizing between residents and/or rooms. Licensed Nurse 9 stated the census had consistently been around 27 recently. Review of the Assignment Sheet dated 11/11/19, showed four licensed nurses were scheduled to work from 1900 to 0700 hours, and one CNA was assigned to work from 2300 to 0700 hours. Licensed Nurse 9 was asked if the scheduled staffing was enough to meet the needs of the residents. Licensed Nurse 9 stated no, with limited staff they are unable to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 94 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE turn the residents in order to maintain or improve skin integrity as outlined in the residents' plans of care. Licensed Nurse 9 stated they prioritize medications and made sure residents were not sitting in soiled briefs. Licensed Nurse 9 stated they had been understaffed for the past four months. On 11/12/19 at 0525 hours, an interview was conducted with Licensed Nurse 23. Licensed Nurse 23 was asked about the care needs of the residents on the subacute unit. Licensed Nurse 23 stated the licensed nurses were responsible for suctioning the non-ventilator residents, administering medications, and helping turn residents. Licensed Nurse 23 stated the residents did not always get turned when they were not properly staffed because there was not enough time. Licensed Nurse 23 stated she prioritized administering the medications and then turning the residents. On 11/12/19 at 0532 hours, an interview was conducted with RT 1. RT 1 was asked what his duties were on the subacute unit. RT 1 stated he was responsible for the respiratory care for the ventilator dependent residents, including oral care, tracheostomy care, including changing the ties, equipment changes, and treatments. RT 1 stated he did not assist with ADL care or turn/reposition the residents. On 11/12/19 at 0544 hours, a follow-up interview was conducted with Licensed Nurse 9. Licensed Nurse 9 was asked about staffing on the subacute unit on 10/27/19. Licensed Nurse 9 verified only one CNA was scheduled to work from 2300 to 0700 hours. Licensed Nurse 3 stated there was only one nurse for the 1900 to 0700 hours shift. Two additional nurses were contacted and one arrived at the facility around 2100 hours and the other arrived sometime after 2300 hours. As a result, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 95 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications were given late that night. On 11/12/19 at 0743 hours, an interview was conducted with Licensed Nurse 18. Licensed Nurse 18 was asked if the residents on the subacute unit were receiving the required care and services with the current staffing. Licensed Nurse 18 stated turning the residents did not always happen because they were short staffed, but the residents got turned as often as possible. Licensed Nurse 18 stated everything took more time because of how many residents were in contact isolation. On 11/12/19 at 0938 hours, an interview was conducted with CNA 14. CNA 14 was asked if he was able to meet the residents' needs on a regular basis. CNA 14 stated the facility was always short staffed. CNA 14 stated he did not always have time to provide all the care residents required, especially when he was the only CNA working the 2300 to 0700 hours shift. CNA 14 stated he checked the residents for soiled briefs, but was not always able to reposition all of the residents in order to keep the residents from developing skin breakdown due to lack of staffing. On 11/12/19 at 0945 hours, an observation and interview was conducted with CNA 14. CNA 14 was observed while he provided ADL care to a resident in contact isolation. CNA 14 stated he started his shift at 0715 hours, and was just now able to check on this resident for the first time since he arrived. CNA 14 was asked how much assistance this resident required compared to other residents on the unit. CNA 14 stated care for this resident took less time than for other residents on the unit. CNA 14 prepared the wash basin with wipes and soap and began to clean the resident. The resident's brief was noted to be soaked with urine. CNA 14 was unable to say how long this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 96 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident had been sitting in a urine saturated brief. CNA 14 was asked if the licensed staff assisted with ADL care. CNA 14 stated the licensed staff did not have time to assist with ADL care. On 11/12/19 at 1005 hours, CNA 14 had the resident clean and dressed, however, still needed to change the bed linens. From start to finish, this resident required 20 minutes to complete their ADL care. On 11/13/19 at 0711 hours, an interview was conducted with the Administrator. The Administrator was informed if it took 15 minutes to provide care to each resident on the subacute unit one time, it would take one CNA 6.75 hours to see 27 residents without breaks or interruptions. The Administrator was asked if one CNA was able to provide the necessary care for all the 27 residents on the subacute unit. The Administrator stated no and added the projection called for at least two CNAs during the 2300 to 0700 hours shift. On 11/13/19 at 0837 hours, an interview was conducted with the DON. The DON was asked about staffing on the subacute unit. The DON stated the licensed staff on the subacute unit told her they felt bad for the CNAs so they assisted with care but it was nearly impossible (to provide the necessary care). The DON stated she did not know how they did it. On 11/13/19 at 1125 hours, an interview was conducted with Licensed Nurse 28. Licensed Nurse 28 was asked about staffing on the subacute unit. Licensed Nurse 28 stated staffing was not good the last two months, mostly in regards to the CNAs. Licensed Nurse 28 stated most of the residents on the unit were heavy, could not move, and required total assistance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 97 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F730 Nurse Aide Peform Review-12 hr/yr In-Service F730 CFR(s): 483.35(d)(7) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/14/2019 §483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to show documentation of 12 hours of in-service education was provided to the CNAs based on their performance reviews on a yearly basis. This facility failure had the potential for residents to receive unsafe care due to lack of proper CNA training. Findings: On 11/13/19 at 0941 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD was asked to show documentation the CNAs had been provided with the required hours of in-service education. The DSD was unable to show any documentation of in-services prior to July 2019 when he was hired. The DSD stated the facility was unable to find the prior in-services, including dementia training since the prior recertification survey in November 2018.

F732 SS=B Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4)

F732 12/14/2019 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 98 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the current staffing was posted daily at the beginning of each shift for a period of three consecutive days. This failure caused the staffing information not being available to residents and visitors to determine if sufficient staff was available to care for the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 99 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: On 11/12/19 at 0635 hours, an observation and concurrent interview was conducted with the Administrator. The staffing information was observed posted near the lobby of the facility; however, the staffing posted was from 11/7 and 11/8/19. The Administrator verified the posted staffing was not current and stated the staff posting should be updated and posted on a daily basis around 1000 hours.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/06/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 100 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review and facility document review, the facility failed to ensure the controlled medication was available, the emergency medications were utilized, the medications were administered timely, and the reconciliation of controlled medications was accurate for three of 34 final sampled residents (Residents 57, 100 and 102), one of five unnecessary medication sampled residents (Resident 34), and six nonsampled residents (Residents 8, 13, 14, 350, 351, and 655). * Resident 100 was not administered her PRN Norco (opioid pain medication) for severe pain because she was out of the Norco tablets for almost 24 hours. The facility failed to utilize their emergency medication supply to ensure Resident 100 received pain medication to manage her severe pain. These failures resulted in Resident 100's severe pain being unmanaged and Resident 100 feeling fearful, tearful, and helpless because she was unable to receive the pain medication to manage her severe pain. * The facility failed to ensure accurate reconciliation of controlled medications for Residents 8, 13, 14, 17, 34, 100, 102, 350, 351 and 655. These failures posed the risk of diversion of controlled medications and medication errors. * The facility failed to ensure medications were given on time for Residents 57, 117, 39, and 45 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 101 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE due to not having enough nursing staff. This failure put the residents at risk for subtherapeutic medication levels and adverse effects. Findings: Review of the facility's P&P titled Preparation and General Guidelines dated 10/2012 the individual who administers the medication records the administration on the resident's MAR (Medication Administration Record) directly after the medication is given. When PRN medications are administered, the following documentation is provided: date and time of administration, dose, route of administration; complaints or symptoms which the medication was given; the results achieved from giving the dose, and the time results were noted; and, signature or initials of the person recording the medication administration. According to the facility's P&P titled Medication Orders dated 10/2012, refills for controlled medications are requested from the pharmacy five days in advance of need to assure an adequate supply is on hand. 1. Medical record review for Resident 100 was initiated on 10/7/19. Resident 100 was admitted to the facility on 6/25/19. a. Review of the Physician Orders showed an order dated 7/3/19, to administer Norco 5/325 mg two tablets by mouth every six hours as needed for pain management and an order dated 6/25/19, to monitor every shift for pain using the pain intensity scale from 0 to 10 with 0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, and 10 = very severe pain. Review of the Drug Control FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 102 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Receipt/Record/Disposition Form for the Norco showed two tablets of Norco were taken on the following dates: - 11/5/19 at 1230 hours; - 11/6/19 at 0045, 0615, 1300, and 1900 hours; - 11/7/19 at 0500 and 1100 hours; - 11/9/19 at 0000 and 0600 hours; - 11/10/19 at 1800 hours; and - 11/11/19 at 1200 hours. However, review of the Medication Record and Pain Assessment Flow Sheets for November 2019 failed to show documentation Resident 100 was administered the Norco tablets on the above dates and times. On 11/12/19 at 0655 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 7. Licensed Nurse 7 reviewed the medical record and verified the above findings. Licensed Nurse 7 stated they signed the narcotic count sheet whenever a narcotic pain medication was popped from the bubble pack, and signed the Medication Record after the medication was administered. They also fill out the Pain Assessment Flow Sheet to document the date and time of administration, location of the pain, nonpharmacological interventions provided, pain intensity, the result after the pain medication was administered and signature of the nurse administering the medication. Licensed Nurse 7 verified this form was not consistently filled out by the licensed nurses. b. On 11/13/19 at 1045 hours, Resident 100 was observed lying in bed with facial grimacing. When asked how she was, Resident 100 stated she was in pain and she "...ran out" of her pain medication. Resident 100 stated she was last administered the Norco for pain yesterday (11/12/19) at 1200 hours. Afterwards, she was told by the licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 103 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nurses she did not have any available Norco tablets for the pain. Resident 100 stated she did not understand why she ran out of pain medication and the licensed nurses could not tell her when her pain medication would be available. Resident 100 stated she ran out of the pain medication two months ago for five days and she was afraid this would happen again. Review of the Nurses Notes showed an entry dated 11/13/19 at 0400 hours, regarding Resident 100 requesting the Norco for pain. The entry showed the licensed nurse called the pharmacy at 0030 hours and was told they were awaiting the "MD Continuation Form." On 11/13/19 at 1053 hours, an interview was conducted with Licensed Nurse 3. Licensed Nurse 3 verified Resident 100 was out of her Norco for pain since yesterday because the pharmacy had not sent the refill. Licensed Nurse 3 stated they should have requested a refill of the Norco 5-7 days before it ran out. Licensed Nurse 3 stated she thought the medication refill was requested because the reorder label was already taken off. Licensed Nurse 3 stated the pharmacy was waiting for the physician's signature because the refill was only requested yesterday. When asked if the facility had an emergency kit, Licensed Nurse 3 stated yes, but she did not think Norco was available in the emergency kit. When asked if she had checked the emergency kit for the availability of the Norco, Licensed Nurse 3 stated no. Review of the list of medications available in the facility's Automated Drug Dispensing System showed Norco 5/325 mg and 10/325 mg tablets were available. Cross reference to

F697. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 104 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. On 11/12/19 at 1027 hours, an inspection of Medication Cart 2 at Station 3 was conducted with Licensed Nurse 24. The following were observed: a. Review of the Drug Control Receipt/Record/Disposition Form for the Norco 5-325 mg tablets for Resident 13 showed 24 of the 30 tablets were popped from the bubble pack (a card where medications are placed in individual clear sealed bubbles) from 11/3 to 11/12/19. However, review of Resident 13's Medication Record for November 2019 showed only two initials dated 11/8 and 11/11/19, to document Resident 13 was administered Norco. The back portion of the form where the licensed nurses were supposed to document the date and time the medication was given, the reason for giving the medication, the result after the medication was administered and initials of the licensed nurse giving the medication was left blank. Medical record review for Resident 13 was initiated on 11/12/19. Resident 13 was admitted to the facility on 1/4/19. Review of the Physician Orders showed an order dated 9/25/19, for Norco 5-325 mg one table via GT every four hours PRN for moderate to severe pain (7-10). Review of the Pain Assessment Flow Sheets for November 2019 showed the Norco 5-325 mg tablet was administered to Resident 13 on 11/4/19 (no time documented), 11/8/19 at 1215 hours, and 11/11/19 at 0000 hours. Twenty one of 24 Norco tablets removed from the bubble pack failed to show documentation of administration to Resident 13. b. Review of the Drug Control FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 105 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Receipt/Record/Disposition Form for the Norco 5-325 mg tablets for Resident 351 showed 15 of 30 tablets were removed from the bubble pack from 11/9 to 11/12/19. However, review of Resident 351's Medication Record for November 2019 showed only five initials showing the Norco tablets were administered to Resident 351 from 11/9/19 at 1900 hours to 11/12/19. The back portion of the form where the licensed nurses were supposed to document the date and time the medication was given, the reason for giving the medication, the result after the medication was administered and initials of the licensed nurse giving the medication was left blank. Medical record review for Resident 351 was initiated on 11/12/19. Resident 351 was admitted to the facility on 5/24/19. Review of the Physician Orders showed an order dated 10/20/19, for Norco 5-235 mg one tablet PRN for moderate pain (4-6) and two tablets for severe pain (7-10). Review of Resident 351's Pain Assessment Flow Sheets for November 2019 showed nine of 15 tablets removed from the bubble pack were not documented as administered to Resident 351 from 11/9/to 11/12/19. c. Review of the Drug Control Receipt/Record/Disposition Form for tramadol (narcotic pain medication) 50 mg tablets for Resident 350 showed 12 of 15 tablets were removed from the bubble pack from 11/7 to 11/12/19. However, review of Resident 350's Medication Record for November 2019 showed only five initials showing the tramadol tablets were administered to Resident 350. The back portion of the form where the licensed nurses were supposed to document the date and time the medication was given, the reason for giving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 106 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the medication, the result after the medication was administered and initials of the licensed nurse giving the medication was left blank. Medical record review for Resident 350 was initiated on 11/12/19. Resident 350 was admitted to the facility on 7/25/19. Review of the Physician Orders showed an order dated 10/9/19, for tramadol 50 mg, give one tablet, by mouth every four hours PRN for moderate to severe back or leg pain. Review of the Pain Assessment Flow Sheets for November 2019 showed seven of 12 tablets removed from the bubble pack were not documented as administered to Resident 350 from 11/7 to 11/12/19. Licensed Nurse 24 was informed and verified the above findings. 3. On 11/12/19 at 1012 hours, an observation, interview, medical record review, and concurrent inspection of Medication Cart 3 on Station 3 was conducted with Licensed Nurse 4. Review of Resident 14's Drug Control Receipt/Record/Disposition Form for Ativan (antianxiety medication) 0.5 mg showed one tablet of Ativan 0.5 mg was removed from the bubble pack on 11/12/19 at 0400 hours. However, review of Resident 14's Medication Record for November 2019 showed no documentation the nurse had signed the record to identify Ativan 0.5 mg was administered to Resident 14 on 11/12/19. Licensed Nurse 4 verified the findings. 4. On 11/12/19 at 1100 hours, inspection of Medication Cart 1 on Station 3 was conducted with Licensed Nurse 16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 107 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 8's Drug Control Receipt/Record/Disposition Form for hydromorphone (controlled narcotic pain medication) 2 mg showed one tablet of hydromorphone 2 mg was removed from the bubble pack on 10/9, 10/11, 10/12, and 10/18/19. However, review of Resident 8's Medication Record for October 2019 showed no documentation the nurse had signed the record to identify hydromorphone 2 mg was administered to Resident 8 on 10/9, 10/11, 10/12, and 10/18/19. Licensed Nurse 16 verified the findings. 5. Review of Resident 17's Drug Control Receipt/Record/Disposition Form for Norco 5325 mg showed one tablet of Norco was removed from the bubble pack on 11/6/19 at 1500 and 2100 hours. Review of Resident 17's Medication Record for November 2019 showed no documentation the nurse had signed the record to identify Norco 5 -325 mg was administered to Resident 8 on 11/6/19 at 1500 and 2100 hours. 6. Review of Resident 34's Drug Control Receipt/Record/Disposition Form for Norco 5325 mg, showed one tablet of Norco 5-325 mg was removed from the bubble pack on 9/20/19, 10/5, 10/12, 10/20, 10/24, 10/25, 10/26, and 11/6/19. However, review of Resident 34's Medication Records for September, October, and November 2019 failed to show documentation Norco 5-325 mg was administered on these eight dates. Licensed Nurse 16 verified above findings. 7. On 11/13/19 at 1132 hours, an interview, medical record review, and concurrent inspection of Medication Cart 2 on Station 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 108 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was conducted with Licensed Nurse 3. Licensed Nurse 3 stated the process for administering controlled medications was to verify the physician's order, document the removal of the medication in the Drug Control Disposition Form and then document the administration of the medication in the Medication Record. Resident 102's Drug Control Receipt/Record/Disposition Form for zolpidem (controlled insomnia medication) 10 mg showed the medication was counted daily from 10/13 to 11/12/19, with one pill removed on each day. Review of the Physician Orders showed an order dated 10/23/19, to administer one tablet of zolpidem tartrate 10 mg by mouth at bedtime for insomnia. Review of Resident 102's Medication Record dated 10/19 failed to show zolpidem was administered to Resident 102 on 10/25 and 10/26/19. Review of Resident 102's Medication Record dated 11/19 failed to show zolpidem was administered to Resident 102 on 11/6/19 and 11/7/19. Licensed Nurse 3 verified the above findings. 8. Review of the Drug Control Receipt/Record/Disposition Form for Resident 655 showed one tablet of tramadol 50 mg was removed on 11/7/19. However, review of Resident 655's Medication Record for November 2019 failed to show documentation tramadol 50 mg was administered to Resident 655 on 11/7/19. Licensed Nurse 3 verified the finding. 9. On 11/7/19 at 0952 hours, an interview was conducted with Resident 57. Resident 57 stated on 10/27/19, on the 1900 hours to 0700 hours shift, there was only one licensed nurse working until the facility found more nurses to work later in the shift. Resident 57 stated she was supposed to receive her medications at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 109 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2100 hours, but was not administered her medications until 2300 hours that night. Medical record review for Resident 57 was initiated on 11/7/19. Resident 57 was admitted to the facility on 6/12/12. Review of the MDS dated 8/30/19, showed Resident 57 was cognitively intact. Review of the Physician Orders showed an order dated 10/4/19, to administer two capsules of fish oil 500 mg every 12 hours for high triglyceride and an order dated 10/24/19, to administer one tablet of Valium (anti-anxiety medication) 2.5 mg at bedtime for muscle spasms. Review of the Nursing Staffing Assignment and Sign-in Sheet dated 10/27/19, showed two licensed nurses called in sick and one licensed nurse failed to report to work for the 1900 to 0700 hours shift. Only one licensed nurse was on duty. On 11/12/19 at 0536 hours, an interview was conducted with Licensed Nurse 9. Licensed Nurse 9 stated she was the only licensed nurse on duty on that shift (10/27/19, 1900 to 0700 hours) until the facility found more licensed nurses willing to come in later in the shift. Licensed Nurse 9 stated Licensed Nurse 26 arrived at 2200 hours and was assigned to Resident 57. Licensed Nurse 9 acknowledged most of the residents' medications were administered late that shift. On 11/13/19 at 1019 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 27. Licensed Nurse 27 stated Resident 57 had two medications due at 2100 hours, the fish oil and the Valium. Licensed Nurse 27 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 110 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications were supposed to be administered within one hour of their scheduled administration times. On 11/13/19 at 1135 hours, an interview was conducted with the Administrator. When asked what time Licensed Nurse 26 arrived to work on 10/27/19, the Administrator provided a hand-written and signed copy of the times License Nurse 26 clocked-in and out for her shift. The Administrator verified Licensed Nurse 26 clocked-in for work at 2200 hours on 10/27/19. Cross reference to F725.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 12/14/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 111 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon timely for three of 34 final sampled residents (Residents 1, 83, and 100). * The Pharmacy Consultant's recommendations for Resident 100 to have a pain consult and to obtain a duration for use of Lovenox (blood thinner) were not acted upon since the date of recommendation on 9/23/19. * The Pharmacy Consultant's recommendations to obtain a stop date for Resident 1's Pyridium (medication to treat urinary problems) was not acted upon since the date of recommendation on 9/23/19. * The Pharmacy Consultant's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 112 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recommendations to include the special instructions on handling one of Resident 83's medications was not acted upon since the date of recommendation on 9/23/19. These failures posed the risk for residents to have significant adverse effects from the medications. Findings: 1. Medical record review for Resident 100 was initiated on 10/7/19. Resident 100 was admitted to the facility on 6/25/19. Review of the Consultant Pharmacist's Medication Regimen Review dated 9/23/19, showed the following recommendations: - For Resident 100 to have a pain consult due to the frequent requests for Norco (narcotic pain medication) with pain scales of 8 out of 10 (on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain); and - Obtain a duration of therapy for Lovenox and update the Medication Record. Review of the medical record failed to show documentation Resident 100's physician was informed of the above recommendations by the Pharmacy Consultant. Review of the medical record failed to show a pain consult was obtained since the Pharmacy Consultant's recommendation on 9/23/19. Review of the Pain Assessment Flow Sheets and Medication Records for September, October, and November 2019 showed Resident 100 had been assessed to have severe pain (8 out of 10) almost every shift and was administered the Norco tablets. Review of the Physician Orders showed an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 113 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order dated 6/25/19, for Lovenox 40 mg, inject subcutaneously (under the skin) daily. The order did not contain a duration of therapy as recommended by the Pharmacy Consultant on 9/23/19. On 11/13/19 at 1132 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 6. Licensed Nurse 6 reviewed the medical record and verified the above findings. Licensed Nurse 6 verified there was no pain consult obtained for Resident 100 despite continued complaints of severe pain with requests for the Norco tablets, and Resident 100 continued to receive Lovenox injections since 6/25/19, without a duration of therapy. Cross reference to F697. 2. Medical record review for Resident 1 was initiated on 11/7/19. Resident 1 was readmitted to the facility on 10/7/19. Review of the Consultant Pharmacist's Medication Regimen Review dated 9/23/19, showed a recommendation to obtain a stop date for the Pyridium because this medication was intended to be used for a short period of time. Review of the Physician Orders showed an order dated 10/15/19, for Pyridium one tablet, by mouth three times a day for neurogenic bladder. The order had no stop date. Review of the Medication Records for September, October, and November 2019 showed Resident 1 was administered Pyridium three times a day from 9/1 to 9/19/19 and 10/15/19 to present. On 11/13/19 at 1140 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 6. Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 114 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nurse 6 reviewed the medical record and verified the above findings. Licensed Nurse 6 stated Resident 1 was transferred out to the general acute care hospital, however, upon Resident 1's return to the facility, the physician should have been informed and a stop date should have been obtained for the Pyridium as recommended by the Pharmacy Consultant. 3. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19, and was readmitted on 10/29/19. Review of the Consultant Pharmacist's Medication Regimen Review dated 9/23/19, showed a recommendation to include as part of the order for Resident 83's Proscar (medication to treat enlarged prostate) the following verbiage: "If pregnant use gloves to handle Proscar: use mask and gloves if crushing is required." The medication, if handled by pregnant women, could cause fetal abnormalities. Review of a physician order dated 10/29/19, showed to administer Proscar 5 mg, one tablet, via GT daily. There was no instruction on handling the medication for pregnant women included in the order. On 11/13/19 at 1138 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 6. Licensed Nurse 6 reviewed the medical record and verified the above findings. Licensed Nurse 6 was unable to provide documentation the Pharmacy Consultant's recommendation was acted upon since 9/23/19.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs FORM CMS-2567(02-99) Previous Versions Obsolete

F757 Event ID: U01H11 12/14/2019 Facility ID: CA060000164 If continuation sheet 115 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.45(d)(1)-(6) §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one nonsampled resident (Resident 349) was free of unnecessary medication. Licensed Nurse 3 administered a laxative to Resident 349 although Resident 349 was having liquid stools. This failure put Resident 349 at risk for adverse effects such as severe diarrhea, abdominal pain, bloating, cramping, and/or nausea. Findings: Medical record review for Resident 349 was initiated on 11/8/19. Resident 349 was admitted to the facility on 9/6/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 116 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 349's Physician Orders showed an order dated 9/6/19, to administer polyethylene glycol (a laxative medication) one packet once daily for bowel management. Review of Resident 349's Bowel Consistency Report for November 2019 showed Resident 349 had liquid stools on 11/1, 11/2, and 11/6/19. Review of Resident 349's Medication Record for November 2019 showed Resident 349 received polyethylene glycol one packet once daily from 11/1/19 to 11/8/19, including the above dates when she had liquid stools. On 11/8/19 at 0930 hours, an interview was conducted with Licensed Nurse 3. Licensed Nurse 3 was asked when Resident 349 last had a bowel movement and the consistency. Licensed Nurse 3 stated she did not know, she would need to ask the CNA. Licensed Nurse 3 verified she did not know or ask about Resident 349's bowel movements or consistency prior to administering a laxative.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 12/14/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 117 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: 4. Medical record review for Resident 52 was initiated on 11/8/19. Resident 52 was readmitted to the facility on 10/29/19. Review of Resident 52's Physician's Telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 118 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Orders showed an order dated 11/1/19, to administer lorazepam 0.5 mg by mouth every six hours as needed for anxiety. On 11/8/19 at 0857 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 13. Licensed Nurse 13 reviewed Resident 52's order for lorazepam and stated Resident 52 was NPO (nothing by mouth) so the order needed to be clarified. Licensed Nurse 13 verified there was no duration for the use of the psychotropic medications.Based on interview and medical record review, the facility failed to ensure four of 34 final sampled residents (Residents 83, 52, 102, and 145) and two of 5 unnecessary medication sampled residents (Residents 1 and 34) were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 1 was administered an antianxiety medication according to the physician's order. * The facility failed to ensure Residents 34, and 145's orthostatic blood pressures (the blood pressure measured while laying down or sitting and again upon standing up) were monitored as ordered by the physicians, related to the use of antipsychotic medications. * The facility failed to ensure the PRN orders for psychotropic drugs for Residents 83 and 52 were limited to 14 days or had a documented rationale from the physicians for the appropriateness of extending the PRN orders beyond 14 days. * The facility failed to ensure Resident 102 was administered a controlled insomnia medication according to the physician's order. These failures had the potential for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 119 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents to experience adverse consequences from the psychotropic medications. Findings: 1. Medical record review for Resident 1 was initiated on 11/7/19. Resident 1 was readmitted to the facility on 10/7/19. Review of the Medication Record for November 2019 showed Resident 1 was administered Ativan (antianxiety medication) 1 mg one tablet for anxiety on 11/5, 11/9, 11/10, and 11/12/19. Review of the current physician orders failed to show an order for Ativan 1 mg for Resident 1. Review of the Admission Orders Record Continuation showed an order dated 10/15/19, for Ativan 1 mg one tablet by mouth every eight hours PRN for anxiety/agitation for 14 days. Review of the Medication Record for October 2019 showed the stop date for the PRN Ativan was 10/29/19. However, Resident 1 was administered Ativan 1 mg on 10/31/19, after the stop date. On 11/12/19 at 0742 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 15. Licensed Nurse 15 verified the above findings and stated Resident 1 was administered the Ativan 1 mg after the stop date ordered by the physician. 2. Medical record review for Resident 34 was initiated on 11/12/19. Resident 34 was admitted to the facility on 7/21/18. Review of the Physician Orders showed orders dated 10/14/19, for Zyprexa (antipsychotic medication) 10 mg, one tablet, by mouth, at bedtime, for schizoaffective disorder FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 120 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE manifested by yelling out; and to monitor for orthostatic blood pressure (sitting and lying) weekly on Sundays. Review of the Medication Record for November 2019 showed the orthostatic blood pressure (sitting and lying) was scheduled to be monitored on 11/3, 11/10, 11/17, and 11/24/19. However, they were not signed or initialed as done. Further review showed a form to document the blood pressure readings (sitting and standing) was blank. On 11/12/19 at 1339 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 16. Licensed Nurse 16 was asked how to obtain the orthostatic blood pressure readings. Licensed Nurse 16 stated Resident 34 was unable to stand up, so the resident's orthostatic blood pressures would be obtained with the resident lying down and again when sitting up. Licensed Nurse 16 verified the orthostatic blood pressure was not monitored as ordered by the physician for November 2019. 3. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19, and readmitted on 10/29/19. Review of the Physician's Telephone Orders dated 11/6/19, showed an order for Ativan 0.5 mg, one tablet every 12 hours PRN for anxiety. The order did not have a stop date. Review of the medical record, failed to show the physician or prescribing practitioner documented a rationale for the appropriateness of extending the as needed order for Ativan beyond 14 days. On 11/8/19 at 0930 hours, an interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 121 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE concurrent medical record review was conducted with Licensed Nurse 13. Licensed Nurse 13 reviewed the medical record and verified the above findings. 5. Medical record review for Resident 102 was initiated on 11/7/19. Resident 102 was admitted to the facility on 6/22/19. Review of the Physician Orders showed an order dated 10/23/19, to administer one tablet of zolpidem tartrate (controlled insomnia medication) 10 mg by mouth at bedtime for insomnia for 14 days. On 11/13/19 at 1132 hours, an interview and medical record review was conducted with Licensed Nurse 3. Licensed Nurse 3 stated, according to Resident 102's physician's order for zolpidem, the stop date was 11/5/19. Review of Resident 102's Medication Record dated 11/19 showed Resident 102 was administered zolpidem 10 mg on 11/8, 11/9, 11/10 and 11/12/19, after the stop date. Licensed Nurse 3 verified the above findings and stated it was the licensed nurse's responsibility to clarify with the physician before administering a medication after the stop date. 6. According to the Highlights of Prescribing Information for Risperidal (antipsychotic medication) from the Food and Drug Administration, Section 5.9 of Warnings and Precautions showed to monitor for orthostatic vital signs. Under Section Possible Side Effects of Risperidal, the drug could cause a decrease in blood pressure and syncope (fainting) when rising too quickly from a sitting or lying position (orthostatic hypotension). Section 8.5 of Geriatric Use showed Risperidal is substantially excreted by the kidneys and reactions may be greater in patients with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 122 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE impaired renal function. Medical record review for Resident 145 was initiated on 11/7/19. Resident 145 was admitted to the facility on 10/19/19. Review of the History and Physical Examination dated 1/8/17, showed Resident 145 had a diagnosis of stage 4 chronic kidney disease. Review of Resident 145's Physician orders dated 10/13/19, showed to monitor for side effects of Risperidal, including postural hypotension. Review of Resident 145's Medication Record for November 2019 showed to monitor orthostatic hypotension weekly every Sunday in the sitting and standing position. On 11/3/19, a single sitting blood pressure was documented. On 11/10/19, no blood pressure was documented for the sitting or standing position. On 11/13/19 at 1555 hours, an interview was conducted with Licensed Nurse 25. Licensed Nurse 25 stated the reason Resident 145 was ordered orthostatic blood pressures was because he was taking Risperidal. Licensed Nurse 25 verified Resident 145's Medication Record showed no orthostatic blood pressure was taken on 11/10/19, and only a sitting blood pressure was taken on 11/3/19.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 12/14/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 123 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure a medication was labeled accurately for one of 34 final sampled residents (Resident 102). The bubble pack (a card where medications are placed in individual sealed compartments) label and instructions were not in accordance with the physician's order. This posed the risk of medication administration errors. Findings: On 11/13/19 at 1132 hours, an interview, medical record review and concurrent inspection of Medication Cart 2 on Station 1 was conducted with Licensed Nurse 3. Resident 102's bubble pack for zolpidem 10 mg was observed with three of 30 pills remaining FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 124 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and showed a delivery date of 10/9/19. Review of the label on the bubble pack showed to administer one tablet of zolpidem by mouth at bedtime as needed for sleep. A new bubble pack for zolpidem 10 mg had 30 pills and showed a delivery date of 11/9/19. Review of the label on the new bubble pack showed to administer one tablet of zolpidem by mouth at bedtime as needed for sleep. Review of the Physician Orders for Resident 102 showed an order dated 10/23/19, to administer zolpidem titrate 10 mg, one tablet at bedtime for insomnia for 14 days then reevaluate. Licensed Nurse 3 verified the above findings. Licensed Nurse 3 stated she believed the correct physician's order dated 10/23/19, did not get faxed to pharmacy because the sticker on the bubble pack was missing. Licensed Nurse 3 explained the sticker was faxed to the pharmacy and was therefore re-ordered to reflect the incorrect order on the bubble pack. Licensed Nurse 3 stated if the physician's order dated 10/23/19, was faxed, the bubble packs would have shown the correct order with only 14 pills delivered.

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 12/14/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 125 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed for three of 34 final sampled residents (Residents 126, 139, and 142). * A soup recipe was not followed by one of the cooks. * The facility failed to follow the menus for Residents 126, 139, and 142. These failures placed residents at risk for compromised nutritional status as a result of the food not meeting their nutritional needs. Findings: Review of the CMS 672 Census and conditions of Residents dated 11/7/19, and signed by the DON showed 120 of the 172 residents residing in the facility received food prepared in the kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 126 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. On 11/8/19 at 1005 hours, Cook 2 was observed pouring a package of pre-steamed vegetables and chicken dumplings into a pot of boiling water. On 11/8/19 at 1018 hours, Cook 2 verified the soup she made was called "rice cake soup" and included the vegetables and chicken dumplings. Review of the facility's recipe (undated) titled Rice Cake Soup did not show vegetables and chicken dumplings as part of the required ingredients. On 11/13/19 at 1202 hours, an interview was conducted with the RD. The RD stated using vegetables and chicken dumplings and not following the recipe was a concern because rice cake soup was a staple item on the menu. 2. On 11/8/19 at 0752 hours, Resident 126's breakfast was observed. When Resident 126 received her breakfast tray, Resident 126 stated she wanted to have hot oatmeal but she did not receive oatmeal. Observation of Resident 126's dietary meal ticket showed oatmeal cereal was on her dietary meal ticket. CNA 13 was asked if there was any reason why Resident 126 did not receive her oatmeal cereal. CNA 13 stated she was not sure. CNA 13 verified Resident 126 did not received her oatmeal cereal as per the dietary meal ticket. 3. On 11/7/19 at 0814 hours, Resident 142's breakfast was observed. Observation of Resident 142's breakfast dietary meal ticket dated 11/7/29, showed honey thickened apple juice, honey thickened milk, pureed French toast, pureed oatmeal cereal, and pureed scrambled eggs. Observation of Resident 142's meal tray showed there was no pureed scrambled egg. CNA 4 verified pureed scrambled eggs were not served to Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 127 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 142. On 11/12/19 at 0725 hours, Resident 142's breakfast was observed. RNA 3 was assisting Resident 142. Observation of Resident 142's breakfast meal ticket showed Resident 142 was supposed to have pureed scrambled eggs. However, observation of Resident 142's breakfast meal tray showed there were no pureed scrambled eggs. RNA 3 was asked if she should have checked the residents' meal tickets. RNA 3 stated no, because the kitchen staff already checked it before sending out the meal tray. RNA 3 stated she just assisted residents for feeding. On 11/12/19 at 0816 hours, an interview was conducted with the DSS. The DSS was asked if there was a reason why Resident 142's pureed scrambled eggs were not served for two days. The DSS stated the pureed scrambled eggs were missed during the meal preparation. 4. On 11/7/19 at 1155 hours, a lunch observation was conducted in the first floor dining room. Resident 139 was observed being assisted for lunch by RNA 1. Review of Resident 139's meal ticket showed she was supposed to receive a half cup of fortified mashed potatoes. However, review of the meal tray showed Resident 139 did not have the fortified mashed potatoes. RNA 1 verified the findings and continued feeding Resident 139 with what was on the meal tray. RNA 1 did not inform the kitchen staff to provide the missing fortified mashed potatoes. On 11/7/19 at 1213 hours, the RD was called and verified the above findings. The RD stated she will go and get the fortified mashed potatoes for Resident 139.

F810 Assistive Devices - Eating Equipment/Utensils FORM CMS-2567(02-99) Previous Versions Obsolete

F810 Event ID: U01H11 12/14/2019 Facility ID: CA060000164 If continuation sheet 128 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.60(g) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(g) Assistive devices The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 34 final sampled residents (Resident 69) was provided with an assistive eating device during mealtimes. This failure could potentially impact Resident 69's nutritional status. Findings: On 11/7/19 at 1155 hours, a lunch observation was conducted in the first floor dining room. Resident 69 was observed feeding himself using only the left hand. Resident 69 was observed carefully scooping the food from a regular plate. There was no adaptive equipment observed. Medical record review for Resident 69 was initiated on 11/7/19. Resident 69 was admitted to the facility on 2/11/03. Review of the Quarterly MDS dated 9/5/19, showed Resident 69 had no cognitive impairment. Review of the Physician Orders showed an order dated 5/5/05, for Resident 69 to use a plate guard to assist in his feeding skills. On 11/8/19 at 0819 hours, Resident 69 was observed for breakfast in his room. Resident 69 was observed feeding himself using his left FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 129 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hand. His right hand was observed to have contractures. Review of the meal ticket failed to show Resident 69 was to use a plate guard to assist with his feeding skills. Resident 69 stated his meal tray never came with a plate guard. On 11/8/19 at 0831 hours, the RD was called to Resident 69's room and verified the above findings. The RD stated Resident 69 would benefit using a plate guard because he could only use one hand for eating.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 02/06/2020 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure sanitary requirements were met in the kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 130 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE * The facility failed to ensure refrigerated food items were properly labeled and dated. * There were expired food items in the kitchen refrigerators. * The staff did not use proper hand hygiene. * The facility failed to monitor refrigerator temperatures for a resident refrigerator. * The facility failed to ensure kitchen equipment was clean prior to use. * The facility failed to air dry equipment and utensils (plate covers, drinking glasses, a blender, water pitchers). These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Condition of Residents dated 11/7/19, and signed by the DON showed 120 of the 172 residents residing in the facility received food prepared in the kitchen. 1. On 11/7/19 at 0708 hours, a tour of the kitchen was conducted with the DSS. A container of sour cream showing an expiration date of 11/5/19, was observed in the kitchen refrigerator. The walk-in refrigerator contained the following: - A container of milk with an expiration date of 11/6/19; - Two bags of beef in clear unlabeled and undated bags; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 131 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - A bag of dark green spinach dated 10/26/19, appeared wrinkly and wilted. On 11/13/19 at 1202 hours, an interview was conducted with the RD. The RD was asked how long a bag of spinach was able to be used once opened. The RD stated fresh produce, such as spinach, had to look crisp, smell fresh, and not look wilted. The DSS verified the above items were past the discard date and should not have been in the refrigerators. The DSS stated the bags of beef should have been labeled to legibly display the dates they were stored in the refrigerator. 2. On 11/8/19 at 1015 hours, Cook 1 was observed rinsing the cutting board and knife in the sink and placing a peeled zucchini on top. The DSS stopped cook 1 and removed the cutting board and knife. On 11/8/19 at 1020 hours, Cook 1 was observed touching raw shrimp with gloved hands in the food sink and then grabbed a container of spices. The DSS stopped Cook 1 and instructed her to take off her gloves and wash her hands. 3. On 11/8/19 at 1029 hours, during a puree food preparation observation, Cook 1 picked up a dirty blender and approached the food sink to wash the blender. The DSS stopped Cook 1 and instructed her to wash the blender in the back of the kitchen. The blender lid was observed with a light creamy substance on a nearby storage cart. Cook 1 returned 10 seconds later according to clock on the wall and brought back the same blender with small white residual bits left in it. Cook 1 stated she was going to puree one bag of vegetables. The RD was asked if the blender looked clean. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 132 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The RD stated it was not clean and stopped Cook 1 before she pureed the vegetables. The RD took the blender to the back of the kitchen to be cleaned. The Blender was brought back and Cook 1 picked it up to start the puree. The Blender was noted with water in the bottom of the blender. The RD was asked if the blender was okay to use with water inside and the RD stated it was fine. The DSS stated it was fine to use because it had just come back from the wash. Cook 1 grabbed the dirty blender lid and placed it on top of the blender and started to puree the vegetables. The DSS stopped Cook 1 and explained to her she could not use a dirty lid to puree the food and informed Cook 1 she now had to make new vegetables. 4. On 11/8/19 at 1053 hours, Cook 1 was observed at the food sink. Cook 1 picked up Bok Choy vegetables and began to cut them. Cook 1 walked away from the sink and, with the same gloves, picked up a container of beef and poured it into the blender for puree. Cook 1 then walked to the counter and, with the same gloves, picked up vegetable spray and placed it on another counter. With the same gloves, Cook 1 picked up a scoop of food thickener and poured it into the blender with the beef. Cook 2 walked over to Cook 1 and stopped the puree. Cook 2 stated to Cook 1 she needed to use beef base liquid, not thickener to puree the beef. On 11/8/19 at 1100 hours, the DSS stated they would be heating up emergency food to serve for the Vietnamese puree menu. On 11/8/19 at 1116 hours, Cook 2 walked out of the walk-in refrigerator and closed the door with gloved hands. With the same gloves, Cook 2 grabbed a scoop out of a drawer, holding it by the scoop not the handle. The DSS verified the above and instructed Cook 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 133 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to wash her hands and grab a new scoop. 5. On 11/8/19 at 1130 hours, during tray-line observation, food container lids were noted with water on the inner lids. Dietary Aide 2 was observed placing lids with water to cover the residents' plates containing food. The RD verified the above and stated it was fine because it was just water. On 11/8/19 at 1500 hours, an interview was conducted with the Assistant Dietary Manager. The Assistant Dietary Manager was notified about the above container lids and stated he expected equipment to be completely air dried. On 11/13/19 at 1006 hours, Dietary Aide 1 was observed stacking dishes to air dry in the kitchen. A tray of about 50 stacked drinking glasses was observed with water inside the glasses. The DSS verified the above and removed all the drinking glasses. A tray of about 20 water pitchers was noted stored upside-down on a solid tray with water dripping on the sides. The DSS was asked to look inside the pitchers. The DSS verified there was water inside the water pitchers and removed them. According to the USDA Food Code 2017, 4901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. 6. On 11/13/19 at 1020 hours, an interview and concurrent inspection of Station 2's resident refrigerator was conducted with Licensed Nurse 14. Review of the Personal Refrigerator Temperature Log for November FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 134 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2019 failed to show Station 2's resident refrigerator temperature was monitored on 11/9, 11/10, and 11/11/19. Licensed Nurse 14 verified the above findings. On 11/13/19 at 1202 hours, an interview was conducted with the RD. The RD stated water pitchers should be placed on an airy surface to dry for infection control purposes.

F813 SS=D Personal Food Policy CFR(s): 483.60(i)(3)

F813 12/14/2019 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure foods brought into the facility for residents were properly stored for safe consumption in two of three resident refrigerators. * The facility failed to ensure the food items stored in the residents' refrigerators were labeled with the residents' names and the dates the food was brought in. The facility failed to ensure the expired food items were discarded. These failures had the potential to result in foodborne illnesses in a highly susceptible resident population. Findings: Review of the facility's instruction sheet for resident's foods titled Resident's Food Only (undated) showed foods could be stored in the resident refrigerator for only 72 hours before being discarded. All food and drinks must be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 135 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE labeled with the resident's name, resident room number, and date. If food and drink items are not properly labeled, they are to be discarded. 1. On 11/13/19 at 1020 hours, an inspection of Station 1's resident refrigerator and a concurrent interview was conducted with Licensed Nurse 21. Licensed Nurse 21 stated when outside food was brought in for the residents, staff was to label the food with the resident's name and date, and store the food items in the residents' refrigerator. Licensed Nurse 21 stated the food was to be discarded after two days. The following food items were observed to be opened and unlabeled with a resident's name, room number or date: - A container of fruit; - A bag of food for Resident 102; - An insulated lunch bag containing milk, cereal, and two hard boiled eggs. Licensed Nurse 21 verified the above findings. 2. On 11/13/19 at 1032 hours, an inspection of Station 2's resident refrigerator and concurrent interview was conducted with Licensed Nurse 14. The following food items were observed to be opened and unlabeled without a resident's name, room number, date, or expired: - A sandwich with a received date of 11/6/19; - A clear container with a creamy yellow food substance. Licensed Nurse 14 verified the above findings. Licensed Nurse 14 stated the above food items should have been discarded after 72 hours.

F838 SS=F Facility Assessment CFR(s): 483.70(e)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F838 Event ID: U01H11 12/14/2019 Facility ID: CA060000164 If continuation sheet 136 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 137 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to conduct and document a facility-wide assessment that addressed the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. This failure had the potential of the residents not receiving care and/or treatment services as needed. Findings: On 11/13/19 at 0711 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator was asked where the number of staff needed to ensure to meet the residents' care needs could be found in the facility assessment. The Administrator stated because the staffing numbers changed based FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 138 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on acuity they were not included in the facility assessment. When asked how many licensed staff were needed on the subacute unit per shift, the Administrator stated he did not know until he looked at the current day's staffing numbers. Cross reference to F725.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 12/14/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 139 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure accurate documentation of the medical records for six of 34 final sampled residents (Residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 140 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 67, 69, 81, 83, 122, and 142) and one of five unnecessary medication sampled residents (Resident 34). * The facility failed to ensure the licensed nurses documented after they administered the medications to Residents 34, 69, and 83. * The facility failed to ensure the monthly recapitulated physician's orders, the indication for medication use, and documentation of the Medication Record were accurate for Resident 142. * The facility failed to ensure Resident 67's Continuous Ventilator Flow Sheet was accurate. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and incomplete. Findings: 1. Medical record review for Resident 69 was initiated on 11/7/19. Resident 69 was admitted to the facility on 2/11/03. Review of the Medication Record for November 2019 showed multiple entries that were not signed. For example, Resident 69 was scheduled to be administered Novolog (insulin) 30 units, subcutaneously (under the skin) daily every 1230 hours. However, the medication was not signed to show it was administered on 11/5, 11/6, and 11/7/19. The blood sugar levels and site of injections were blank. On 11/8/19 at 1152 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 3. Licensed Nurse 3 verified the above findings and stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 141 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she administered the medications to Resident 69, but was not able to sign the Medication Record. When asked how she would remember the blood sugar level of Resident 69 the last three days, Licensed Nurse 3 stated she could not. 2. Medical record review for Resident 34 was initiated on 11/12/19. Resident 34 was readmitted to the facility on 7/21/18. Review of the Physician Orders showed an order dated 7/26/18, for alendronate (osteoporosis medication) 70 mg, one tablet by mouth every Monday at 0630 hours. Review of the Medication Record for November 2019 showed the alendronate was scheduled to be administered weekly at 0630 hours on 11/4, 11/11, 11/18, and 11/25/19. However, the medication was not signed to show it was administered to Resident 34 on 11/4 and 11/11/19. On 11/12/19 at 1339 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 16. Licensed Nurse 16 reviewed the medical records and verified the alendronate was not documented as administered on 11/4 and 11/11/19. 3. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19, and readmitted on 10/29/19. Review of the Medication Record for November 2019 showed the medications and other physician's orders scheduled to be given for the 0700 to 1500 hours shift on 11/6 and 11/7/19, were not signed to show the medications were administered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 142 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/8/19 at 1148 hours, an interview was conducted with Licensed Nurse 3. Licensed Nurse 3 reviewed the medical records and verified she did not sign the Medication Record after the medications were administered to Resident 83. Licensed Nurse 3 stated she had a habit of not signing after giving the medications especially when she was busy. 4. Medical record review for Resident 122 was initiated on 11/7/19. Resident 122 was readmitted to the facility on 7/13/15. Resident 122's active medical record contained Resident 700's Restorative Nursing Weekly Summary dated 8/8/19. On 11/7/19 at 1614 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director verified the findings and removed the incorrect record from Resident 122's medical record. 5. Review of Resident 142's Physician's Admission Orders/Medication Record dated 10/11/19, showed an order to administer apixaban (anticoagulant medication) 5 mg one tablet by mouth twice a day for atrial fibrillation. Review of Resident 142's Physician's Order dated 10/17/19, showed to discontinue the previous Eliquis (brand name of apixaban) and re-ordered to administer Eliquis 2.5 mg by mouth twice a day. Review of the Recapitulated Physician Orders from 11/1/19 through 11/30/19, showed the following orders: - An order dated 10/11/19, to administer apixaban 5 mg, one tablet by mouth twice a day for atrial fibrillation. - An order dated 10/17/19, to administer Eliquis (brand name of apixaban) 2.5 mg, one tablet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 143 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by mouth twice a day for DVT (deep vein thrombosis) prophylaxis. Review of Resident 142's Medication Record for October 2019 showed nurses had signed under apixaban 5 mg until 10/17/19, and documented discontinued. The nurses had signed their initials under Eliquis 2.5 mg, starting on 10/18/19. Review of Resident 142's Medication Record for November 2019 showed nurses had signed their initials under apixaban 5 mg, one tablet by mouth twice a day for atrial fibrillation on 11/1, 11/2, 11/3, and 11/4/19 and had documented "error duplicate." The nurses signed their initials under Eliquis 2.5 mg, one tablet by mouth twice a day for DVT from 11/1/19 through 11/7/19. Review of the History and Physical Exam for Resident 142 dated 10/13/19, failed to show Resident 142 had a diagnosis of DVT or a history of DVT. On 11/8/19 at 1202 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 4. Licensed Nurse 4 was asked which anticoagulant Resident 142 was on. Licensed Nurse 4 stated Resident 142 was on Eliquis 2.5 mg for atrial fibrillation. When Licensed Nurse 4 reviewed Resident 142's recapitulated Physician Orders for November, she verified apixaban and Eliquis were the same medication and they were both on the recapitulated physician's orders. Licensed Nurse 4 stated the nurse who received the new order should have discontinued the previous order. However, when the nurse entered the new order, which was Eliquis 2.5 mg to the system, the nurse did not discontinue the previous order for apixaban 5 mg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 144 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Nurse 4 verified Resident 142 did not have a diagnosis of DVT or a history of DVT. Licensed Nurse 4 could not find DVT as an indicator for the use of Eliquis in the physician's order. On 11/12/19 at 0838 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the current recapitulated Physician Orders, the indication for the use of Eliquis, and the documentation on Resident 142's Medication Record for apixaban were not accurate. 6. On 11/12/19 at 1012 hours, observation, interview, medical record review, and concurrent inspection of Medication Cart 3 on Station 3 was conducted with Licensed Nurse 4. During the medication cart inspection, Resident 81's Ativan 0.5 mg was observed. The label on the Ativan bubble pack showed Ativan 0.5 mg, one tablet by mouth daily as needed for anxiety manifested by obsession problems for 90 days. Review of the Physician Orders for November 2019 showed an order to administer Ativan 0.5 mg, one tablet by mouth daily as needed for anxiety manifested by obsession problems for 90 days. However, review of Resident 81's Medication Record for November 2019 showed to administer Ativan 0.5 mg one tablet by mouth daily PRN for anxiety manifested by obsession problems for 60 days. Licensed Nurse 4 verified the duration of Ativan on the Medication Record did not match the physician's order. 7. On 11/7/19 at 0715, 0932, 1128, 1243, and 1434 hours, Resident 67 was observed in bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 145 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator. The ventilator settings were AC mode, rate of 16, tidal volume 400, and PEEP of 5. Review of Resident 67's Continuous Ventilator Flow Sheet dated 11/7/19, did not accurately show the ventilator settings Resident 67's mechanical ventilator was set to. The entries dated 11/7/19 at 0625, 0825, 1225, 1425, and 1625 hours, inaccurately showed Resident 67 was on SIMV mode, rate of 12, and pressure support of 12. On 11/8/19 at 1101 hours, an interview was conducted with RT 2. RT 2 verified how to check the ventilator settings. RT 2 verified all ventilator setting changes were supposed to be documented. On 11/8/19 at 1111 hours, a telephone interview was conducted with RT 3. RT 3 verified Resident 67's ventilator settings on 11/7/19, was AC mode, rate of 16, tidal volume 400, and PEEP of 5. RT 3 stated he placed Resident 67 on the AC mode in the morning because she was having labored breathing. RT 3 acknowledged the resident's condition and any ventilator setting changes had to be documented. RT 3 verified he should have documented Resident 67 was placed on AC mode, rate of 16, tidal volume 400, and PEEP of 5.

F880 SS=F Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 12/14/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 146 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 147 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to establish and maintain an infection control program designed to help prevent the development and transmission of diseases and infections. * The facility failed to conduct an accurate surveillance of infections as per the McGeer's criteria. This posed the risk of the facility not accurately investigating and preventing new infections from developing and an outbreak going unrecognized within the facility. * The facility failed to ensure the TB screening test was administered to Resident 83 as ordered by the physician. This failure posed the risk of the residents, staff and visitors being exposed to the tuberculosis infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 148 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. According to the facility's P&P titled Infection Control/Prevention Surveillance revised 1/2018, the IP, under the guidance of the Infection Control committee and Medical Director shall be responsible to implement the surveillance program. The McGeer's criteria will be utilized to define infection surveillance activities. Documentation for the surveillance program could include the following: Infection Control Surveillance Log, Infection Control Compliance Audit, MDRO (multi drug resistant organisms) Line Listing, and a facility floor plan for mapping. Results of the surveillance program will be reported at the monthly Infection Control Committee and at the Quarterly Quality Assurance/Continuous Quality Improvement Committee. The IP will report at a minimum the rate of HAIs versus CAIs, the results of the walking rounds and compliance with infection control policies and practices, the results of the data collection, and patterns and trends identified. On 11/13/19 at 0909 hours, an interview and concurrent review of the facility's infection control program was conducted with the IP. The IP stated he was responsible for the facility's Infection Control and Antibiotic Stewardship Programs. The IP stated infection control related concerns were discussed during the QA meeting and there was no separate infection control committee meetings conducted to discuss the infection control surveillance. The IP stated he started attending the QA meetings last September 2019; however, he did not provide a report of his infection control surveillance to the meetings. Review of the facility's Infection Control Surveillance Logs failed to show surveillance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 149 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for the months prior to August 2019. There was no mapping of infections using the facility's floor plan. Review of the Infection Prevention and Control Surveillance Log for August 2019 showed a log for the subacute unit. The log was incomplete and inaccurately filled out. There were a total of five incidents of antibiotic use for the month, two were checked off as HAIs and the rest were blank. Review of the Infection Control Tracking and Trend Log for September 2019 showed there were a total 79 incidents of antibiotic use in the facility. Of the 79 incidents, 14 were CAIs, 15 were HAIs, and 50 were incidents of antibiotic use whose symptoms did not meet the McGeer's criteria in the facility. This was not reported to the Infection Control Committee or QA meetings. Cross reference to F881. The IP verified the above findings. The IP stated he did not do mapping of infections. The results of the surveillance program were not reported at the monthly infection control committee and at the quarterly quality assurance/continuous quality Improvement committee meetings. The rates of HAIs versus CAIs, the results of the walking rounds and compliance with infection control policies and practices, the results of the data collection, and patterns and trends identified were also not reported to the Infection Control Committee and at the quarterly quality assurance/continuous quality improvement committee meetings. 2. Medical record review for Resident 83 was initiated on 11/7/19. Resident 83 was admitted to the facility on 9/18/19, and readmitted on 10/29/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 150 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Physician's Admission Orders/Medication Record dated 10/29/19, showed an order for a TB skin test by administering PPD (purified protein derivative, a test to determine TB) 0.1 ml, intradermally (into the skin), read in 48 to 72 hours. Repeat in 14 days if negative. Review of the Medication Record for October 2019 showed the TB skin test was scheduled to be administered upon readmit on the 1500 to 2300 hours shift. However, the documentation failed to show if the TB skin test was administered on 10/29/19, there was no time or location documented. There was no reading done in the subsequent 48 to 72 hours. On 11/8/19 at 0930 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 13. Licensed Nurse 13 reviewed the medical record and verified the above findings. Licensed Nurse 13 failed to show documentation the TB skin test was administered upon Resident 83's readmission to the facility, and read in 48 to 72 hours.

F881 SS=D Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 12/14/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 151 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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 reported to the Infection Control Committee meetings. As a result, there were no action plans developed to address the inappropriate use of antibiotics in the facility. Findings: According to the CDC (Centers for Disease Control and Prevention), unnecessary antibiotic use promotes development of antibioticresistant 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 Infection Control - Antibiotic Stewardship Program (ASP) revised date 1/2019 showed the ASP team will review the facility's Infection Prevention surveillance log and other reports as indicated. The IP will be responsible for infection surveillance and MDRO (multi drug resistant organism) tracking. The IP and other members of the ASP team will review and report findings to the facility staff and to the Quality Assurance (QA) committee, who will then provide feedback to the facility staff. Educational opportunities as identified by the QA team should be provided for clinical staff as well as residents and their families on appropriate use of antibiotics. On 11/13/19 at 0909 hours, an interview and concurrent review of the facility's infection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 152 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE control program was conducted with the IP. The IP stated he was responsible for the facility's Infection Control and Antibiotic Stewardship Programs. The IP stated infection control related concerns were discussed during the QA meeting and there was no separate ASP meetings conducted to discuss appropriate antibiotic use. The IP stated he did not provide a report of his Infection Control Surveillance to the QA meetings. The IP stated the facility utilized McGeer's Criteria to define infection surveillance activities. Review of the facility's Infection Control Surveillance Logs failed to show surveillance for the months prior to August 2019. (Cross reference to F880, example 1) Review of the Infection Control Tracking and Trend Log for September 2019 showed there were 79 incidents of antibiotic use in the facility. Of the 79 incidents, 14 were CAIs, 15 were HAIs, and 50 incidents of antibiotic use whose symptoms did not meet the McGeer's criteria in the facility. When asked if these very high incidents of antibiotic use not meeting the McGeer's criteria were reported to the ASP or QA meeting, the IP stated no. There was no action plan developed to address the inappropriate use of antibiotics. The IP verified the above findings.

F883 SS=D Influenza and Pneumococcal Immunizations CFR(s): 483.80(d)(1)(2)

F883 12/14/2019 §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 153 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 154 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of 34 final sampled residents (Resident 69) was administered the influenza vaccination when he was eligible and elected to receive the vaccine. This failure posed the risk of Resident 69 acquiring influenza. Findings: Medical record review for Resident 69 was initiated on 11/7/19. Resident 69 was admitted to the facility on 2/11/03. Review of the Pneumococcal and Influenza Vaccine Consent Form dated 3/10/16, showed Resident 69 had requested to be given the influenza vaccine annually. Review of Resident 69's immunization record showed he was last administered the influenza vaccine on 10/11/18. Review of the medical record failed to show documentation Resident 69 was given the influenza vaccine this year. On 11/13/19 at 1248 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 15. Licensed Nurse 15 reviewed the medical record and verified the above findings. Licensed Nurse 15 stated she did not know why Resident 69 did not receive the influenza vaccine last month. On 11/14/19 at 1532 hours, the DON acknowledged Resident 69 was not given the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 155 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE influenza vaccine even though he was eligible and elected to receive one.

F925 SS=D Maintains Effective Pest Control Program CFR(s): 483.90(i)(4)

F925 12/14/2019 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility record review, the facility failed to ensure an environment free of pests for one nonsampled resident (Resident 116). * Resident 116's family reported to the facility the presence of roaches in Resident 116's room. The facility failed to follow up with the pest control company in order to schedule a service visit to Resident 116's room. Approximately two weeks later Resident 116's family again reported the presence of roaches in Resident 116's room. This had the potential for pests to multiply and the presence of pest associated germs and resulted in Resident 116 not being provided a homelike environment. Findings: Medical record review for Resident 116 was initiated on 11/13/19. Resident 116 was admitted to the facility on 6/28/17. On 11/13/19 at 1138 hours, Resident 116's family member (Family Member A) stated there were roaches in Resident 116's room (Room C). Upon entering Room C, Family Member A produced a napkin with approximately six roaches she had killed. Family Member A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 156 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated Resident 116's night stand was full of roaches. Family Member A then moved the night stand and approximately 30 roaches were observed on the back of the night stand. Family Member A stated she had informed facility staff on several occasions over the past several months that Resident 116's room had roaches. Family Member A stated she wanted a new night stand for Resident 116's room, as she was concerned the night stand may contain roach eggs. Family Member A stated she informed Licensed Nurse 4, and Licensed Nurse 4 informed Family Member A facility maintenance had been informed. On 11/13/19 at 1147 hours, an interview and concurrent facility record review was conducted with Licensed Nurse 4. Licensed Nurse 4 stated on 10/29/19, she filled out a maintenance request for Room C. Review of the facility Maintenance Request Log form showed a request entry dated 10/29, for Room C, that showed "a lot of cockroach under drawer." The section for Status and Date Completed, on the Maintenance Request Log form was blank. On 11/13/19 at 1343 hours, an interview and concurrent facility record review was conducted with the Administrator. The Administrator stated the pest control company inspected/performed service at the facility monthly and on an as needed basis. The Administrator verified the facility Maintenance Request Log form showed a request entry dated 10/29, for Room C, that showed "a lot of cockroach under drawer" and the section titled Status and Date Completed on the Maintenance Request Log form was blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 157 of 158 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555103 (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRENCH PARK CARE CENTER 600 E Washington Ave Santa Ana, CA 92701 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The Administrator stated maintenance should have contacted the pest control company and requested the company perform a service for Room C. The Administrator reviewed the facility extermination log and stated the pest control company had not performed services for Room C. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U01H11 Facility ID: CA060000164 If continuation sheet 158 of 158