Health inspection·June 19, 2025

F 0558 Level of Harm - Potential for minimal harm Residents Affected - Some hanging by Resident 1's left side of the bed. Resident 1 was asked if he would prefer his bed remote control within reach, Resident 1 stated he preferred the bed remote control to be within reach. The IP was asked for the facility's process on the placement of the bed remote control for the residents. The IP verified Resident 1's bed remote control should have been placed within Resident 1's reach. Medical record review for Resident 1 was initiated on 6/16/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/5/5, showed Resident 1 had the capacity to make decisions. Review of Resident 1's MDS assessment Section C- Cognitive Patterns dated 5/6/25, showed Resident 1's BIMS score was 15, indicating Resident 1's cognition was intact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 2 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medial record review, and facility P&P review, the facility failed to obtain and/or maintain the copies of the advance directive in the medical record for one of two final sampled residents (Resident 52) reviewed for advance directives. This failure had the potential for the resident's decisions regarding their healthcare and treatment not being honored. Findings: Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives revised 12/2022 showed on admission, the facility will determine if the resident has executed an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Medical record review for Resident 52 was initiated on 6/16/25. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Advance Directive Acknowledgement form dated 10/22/24, showed Resident 52 had executed an advance directive. Review of Resident 52's H&P examination dated 10/23/24, showed Resident 52 had no capacity to understand and make medical decisions. Review of Resident 52's Physician Orders for Life-Sustaining Treatment (POLST) dated 10/31/24, showed Section D - Information and Signatures of the advance directive information was left blank. Review of Resident 52's medical record failed to show a copy of Resident 52's advance directive was maintained in the resident's medical record. Further review of Resident 52's medical record failed to show documented evidence the facility attempted to obtain a copy or follow up regarding Resident 52's advance directive. On 6/19/25 at 0948 hours, a concurrent interview and medical record review was conducted with the SSD and SSA. The SSA stated prior to April 2025 their admissions did the Advance Directive Acknowledgement form, and the Social Services department did not see the forms. The SSD verified the Social Services department was now responsible for the residents' advance directives. The SSD stated they did not have documentation of the follow up or a record of Resident 52's advance directive. On 6/19/25 at 1601 hours, an interview was conducted with the Administrator, DSS, and DON. The Administrator, DSS, and DON acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 3 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to determine whether a resident's grievance allegation was resolved in accordance with the facility's P&P for one of 19 final sampled residents (Resident 53). * Resident 53 stated on 5/9/25, she sustained a skin abrasion to her thigh after a CNA changed her soiled adult brief. Resident 53 stated she sustained the abrasion form a towel the CNA used to clean her. Resident 53 stated the CNA was too rough and hard with the towel when cleaning her. Resident 53 stated the facility failed to address her concern (after having informed the facility on 5/9/25) thus she informed the facility again during a resident council meeting held on 6/12/25. Resident 53 stated the facility has yet to address her concern. * The facility failed to determine whether Resident 53's allegation the CNA was too rough and hard with the towel when cleaning her, was resolved in accordance with the facility's P&P for grievances. These failures posed the risk for the resident's grievance not being thoroughly addressed, investigated, documented, and resolved. Findings: Review of the facility's P&P titled Resident and Family Grievances revised 2/22/23, showed the social services designee has been designated as the facility's grievance official. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form. The grievance official will keep the resident appropriately apprised of the progress towards resolution of the grievances. The grievance official may issue a written decision on the grievance to the resident at the conclusion of the investigation. The written decision will include at a minimum: A summary of the pertinent findings or conclusions regarding the resident's concern. A statement as to whether the grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility as a result of the grievance. The facility will make prompt efforts to resolve grievances. Medical record review for Resident 53 was initiated on 6/16/25. Resident 53 was admitted to the facility on [DATE]. Review of Resident 53's H&P examination dated 4/25/25, showed Resident 53 had the capacity to understand and make decisions. On 6/16/25 at 1327 hours, an interview was conducted with Resident 53. Resident 53 stated on 5/9/25, she sustained a skin abrasion to her thigh after a CNA changed her soiled adult brief. Resident 53 stated she sustained the abrasion form a towel the CNA used to clean her. Resident 53 stated the CNA was too rough and hard with the towel when cleaning her. Resident 53 stated she reported the incident to facility staff on 5/9/25, and no longer wished for this particular CNA to provide care for her. Resident 53 stated the facility failed to address her concern, therefore she again voiced her concern during a resident council meeting held on 6/12/25. Resident 53 stated the facility had not followed up with her and she would like the facility to follow up with her specific concern. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 4 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm On 6/18/25 at 0916 hours, an interview and concurrent facility record review was conducted with the facility's Grievance Official, the SSD. The SSD stated Resident 53 informed her of a grievance on 5/9/25, and she documented Resident 53's grievance on the facility's grievance form. The SSD stated Resident 53 informed her that a CNA caused a skin tear while cleaning her with a towel, during an adult brief change. The SSD stated Resident 53 informed her the CNA was not gentle and cleaned her hard. Residents Affected - Few Review Resident 53's Grievance form dated 5/9/25, showed the SSD documented that a CNA changed Resident 53's adult brief and Resident 53 alleged the CNA caused open skin on Resident 53's left groin. The Grievance form failed to show the SSD documented Resident 53's allegation that the CNA was not gentle and cleaned Resident 53 hard. The SSD stated Resident 53's concern specific to the allegation the CNA was not gentle and cleaned Resident 53 hard should have been included and documented on the Grievance form. Additionally, the SSD stated Resident 53's allegation the CNA was not gentle and cleaned her hard should have been addressed with Resident 53 and a determination made as to whether Resident 53 was satisfied with the facility's investigation, outcomes, and facility interventions. The SSD stated this information should then be documented on Resident 53's Grievance form. The SSD verified the Grievance form section titled Complainant (Resident 53) Satisfied, and Date (Grievance) Resolved were both blank. The SSD stated Resident 53 again voiced her concern during a resident council meeting conducted on 6/12/25. The SSD stated Resident 53's concern was documented on the facility's Department Response Resident Council Concerns Form dated 6/12/25. A review of the Department Response Resident Council Concerns Form dated 6/12/25, was then conducted with the SSD. Documentation showed Resident 53 again voiced her concern specific to the CNA. The facility documented Resident 53 stated a CNA was rough in handling Resident 53 during an adult brief change. Further review of the form showed the department's written response to Resident 53's allegation. The department's response showed documentation specific to whether Resident 53 was to be compensated for a skin tear. However, the department response failed to show a response specific to Resident 53's allegation that the CNA was rough in handling her during an adult brief change. The SSD verified the findings. The SSD stated Resident 53's allegation a CNA was rough in handling her during an adult brief change should have been addressed, and the department's response and resolution documented. Further review of the Department Response Resident Council Concerns Form dated 6/12/25, showed a section as to if the allegation was resolved to Resident 53's satisfaction, with a Yes or No option available, however, this section was blank. The SSD verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 5 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 1) reviewed for unnecessary medications was free from the unnecessary psychotropic medications. * The facility failed to ensure the non-pharmacological interventions were implemented prior to to the administration of the temazepam (a sedative medication used to relieve difficulty of falling asleep) to Resident 1. This failure had the potential to negatively affect the resident's well-being and had the potential for adverse effects from the psychotropic medications. Findings: Review of the facility's P&P titled Use of Psychotropic Medication(s) dated 3/17/25, showed it is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. 5. The indications for initiating, maintaining or discontinuing medication(s), as well as use of non-pharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. 6. Nonpharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication. Medical record review for Resident 1 was initiated on 6/16/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/5/5, showed Resident 1 had the capacity to make decisions. Review of Resident 1's Order Summary dated 6/17/25, showed the following physician's orders: - dated 5/6/25, to administer temazepam 30 mg capsule by mouth at bedtime for insomnia manifested by inability to sleep. - dated 5/6/25, to monitor for side effects related to use of psychotropic medications. - dated 5/20/25, to monitor inability to sleep and record the number of hours of sleep every shift for insomnia. Review of Resident 1's care plan revised 5/5/25, showed a care plan problem addressing Resident 1 was on sedative/hypnotic therapy (temazepam) related to insomnia which included the following interventions: - to administer sedative/hypnotic medications as ordered by physician and monitor/document the side effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 6 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm - to evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, caffeine/medications and attempt to modify and control these external factors before initiating hypnotic therapy. - to precede or accompany hypnotic use by other interventions to try to improve sleep. Residents Affected - Few Review of Resident 1's MAR for May 2025 showed the following hours of sleep every shift for insomnia: - On 5/6, 5/17, 5/22, 5/23, 5/24, and 5/31/25, had seven hours of sleep during the night shift. - On 5/6, 5/8, 5/10, 5/11, 5/14, 5/15, 5/16, 5/17, 5/24, 5/26, 5/30 and 5/31, one hour of sleep during the evening shift. - On 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/15, 5/16, 5/18, 5/19, 5/20, 5/21, 5/25, 5/26, 5/27, 5/28, 5/29, and 5/30/25, had six hours of sleep during the night shift. - On 5/7, 5/11, 5/13, 5/15, 5/22, 5/23, 5/25, 5/26, 5/27, 5/29, 5/30, 5/31/25, had one hour of sleep during the day shift. - On 5/7, 5/9, 5/12, 5/13, 5/20, 5/21, 5/22, 5/23, 5/27, 5/28, and 5/29/25, had two hours of sleep during the evening shift. - On 5/8, 5/9, and 5/16/25, zero hour of sleep during the day shift. - On 5/10, 5/12, 5/14, 5/17, 5/18, 5/19, 5/21, 5/24, and 5/28/25, had two hours of sleep during the day shift. - On 5/14/25, had five hours of sleep during the night shift. - On 5/18, 5/19 and 5/25/25, zero hour of sleep during the evening shift. - On 5/20/25, no documentation on the hour(s) of sleep, during the day shift. Review of the the chart codes and follow-up codes in the MAR for May 2025 showed the following: - [NAME] for Group Observed-All, - OBI for Observed Individual, - OBP for Group Observed -Partial, - 1, for Drug refused, - 2 for hold/see progress notes / Treatment refused, - 3 for vital signs outside parameters of administration and for hospitalized - checkmark for administered, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 7 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 - I for ineffective, Level of Harm - Minimal harm or potential for actual harm - E for effective, - U for unknown, and Residents Affected - Few - H for on hold by physician. Review of Resident 1's MAR for May 2025 showed the X marks from 5/6 to 5/31/25, for NPI (nonpharmacological interventions) for temazepam 30 mg capsule by mouth at bedtime for insomnia as manifested by inability to sleep. The MAR chart codes and prompt legends showed no X for documentation. Further review of the MAR showed no documentation of the nonpharmacological interventions were provided prior to the administration of the temazepam medication. Review of Resident 1's Licensed Progress Notes for 5/2025 failed to show documentation nonpharmacological interventions were implemented prior to the administration of Resident 1's temazepam medication. On 6/18/25 at 0940 hours, an interview and a concurrent medical record review for Resident 1 was conducted with RN 1. RN 1 was asked what was the X mark on the NPI (nonpharmacological intervention box documented by the licensed nurses in the MAR on the physician order for Resident 1's temazepam. RN 1 was also asked to show any documentation of the nonpharmacological interventions implemented prior to the administration of temazepam medication to Resident 1. RN 1 verified she did not know what the X mean as it was not in the MAR chart code, and she was not able to show any documentation of the nonpharmacological interventions were implemented for the administration of the temazepam medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 8 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS was coded accurately for one of 19 final sampled residents (Resident 399). This failure had the potential for the resident to not receive individualized plans of care to address the resident's individual care needs. Residents Affected - Some Findings: Review of the facility's P&P titled Conducting an Accurate Resident assessment dated [DATE], showed all the residents received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Medical record review for Resident 399 was initiated on 6/18/25. Resident 399 was admitted to the facility on [DATE]. Review of Resident 399's admission MDS assessment dated [DATE], showed under Section O, Special Treatments, Procedures, and Programs showed Resident 399 was not coded for hemodialysis. Review of Resident 399's Order Summary Report dated 6/17/25, showed a physician's order dated 6/5/25, for Resident 399's hemodialysis schedule on Mondays, Wednesdays, and Fridays at a contracted dialysis facility. On 6/18/25 at 1241 hours, an interview and concurrent medical record review for Resident 399 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated she coded the MDS assessment incorrectly. On 6/19/25 at 1612 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 9 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed for one of 19 final sampled residents (Resident 40) and two nonsampled residents (Residents 27 and 96). * The facility failed to develop a care plan specific to Residents 27 and 96's preference for Korean food and the residents were subsequently served American food. * The facility failed to develop a care plan problem to address Resident 40's food allergies to shrimp. These failures placed the residents at risk for not being provided appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 27 was initiated on 6/16/25. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27's Nutrition Progress Note dated 6/2/25 at 1716 hours, showed Resident 27 preferred Korean food for lunch and dinner. On 6/17/25 at 1320 hours, an observation was conducted of Resident 27. Resident 27 was observed lying in bed asleep. Resident 27's lunch tray was observed on a bedside table adjacent to Resident 27's bed. Resident 27's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). 2. Medical record review for Resident 96 was initiated on 6/16/25. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's Nutrition Progress Note dated 6/2/25 at 1454 hours, showed Resident 96 preferred Korean food at lunch and dinner. On 6/17/25 at 1246 hours, an observation was conducted of Resident 96. Resident 96 was observed in the dining room eating lunch. Resident 96's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). Resident 96's lunch ticket showed Resident 96 preferred Korean Food. On 6/17/25 at 1555 hours, an interview and concurrent medical record review was conducted with the DSS. The DSS verified Residents 27 and 96 received American pureed food for lunch today (6/17/25) rather than Korean pureed food for lunch in accordance with the residents' food preferences. The DSS then reviewed Residents 27 and 96's care plans and verified the facility failed to develop a care plan specific to Residents 27 and 96's preference for Korean food. Cross reference to F806, examples #2 and #3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 10 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Medical record review for Resident 40 was initiated on 6/17/25. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's admission Record dated 4/7/25, showed Resident 40 had a food allergy to shrimp. Review of Resident 40's plan of care failed to show documented evidence a care plan problem was developed to address Resident 40's food allergy to shrimp. On 6/18/25 at 1347 hours, an interview and concurrent medical record review for Resident 40 was conducted with LVN 4. LVN 4 verified Resident 40 had a food allergy to shrimp. LVN 4 verified and acknowledged there was no plan of care formulated to address Resident 40's allergy to shrimp. On 6/19/25 at 1612 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 11 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTI for one of one final sampled resident (Resident 68) reviewed for urinary catheter or UTI. * Resident 68 had an indwelling urinary catheter (an indwelling catheter used to drain urine from the bladder) and a history of recurrent UTIs. The facility failed to ensure proper positioning of Resident 68's urinary drainage bag to prevent urine from flowing back into the bladder. This failure posed the risk for Resident 68 to develop a CAUTI. Findings: Review of the CDC's Guideline for Prevention of Catheter-Associated Urinary Tract Infections dated 6/2009 under the section titled Proper Techniques for Urinary Catheter Maintenance, showed to keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Medical record review for Resident 68 was initiated on 6/16/25. Resident 68 was readmitted to the facility on [DATE]. Review of Resident 68's SBAR Communication Form dated 6/9/25, showed Resident 68 had a change in condition related to being sleepier than usual. The physician was notified and recommended for the IV fluids, blood tests, and urinalysis test. Review of Resident 68's Nurses Progress Note dated 6/11/25, showed Resident 68 was seen by her physician and the physician had ordered IV antibiotics for seven days for UTI. Review of Resident 68's Order Summary Report dated 6/19/25, showed a physician's order dated 5/7/25, for an indwelling urinary catheter for neurogenic bladder. On 6/17/25 at 1637 hours and 6/18/25 at 1615 hours, Resident 68 was observed lying in bed with a urinary catheter tubing attached to a urinary drainage bag. The urinary drainage bag was observed lying on the floor. On 6/18/25 at 1622 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 verified the findings. LVN 3 verified the urinary drainage bag should not be touching the floor and proceeded to elevate Resident 68's bed. LVN 3 stated the floor was dirty and the bag should not be touching the floor for infection prevention. On 6/19/25 at 0915 hours, an interview was conducted with RN 1. RN 1 stated Resident 68 had frequent UTIs. RN 1 acknowledged the findings. RN 1 stated the urinary drainage bag should be above the floor to prevent infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 12 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician's order for the oxygen therapy was followed for one of one final sampled resident reviewed for oxygen therapy (Resident 70). This failure had the potential to affect the respiratory health and well-being of Resident 70. Residents Affected - Few Note: The nursing home is disputing this citation. Findings: Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed the oxygen was administered under orders of a physician, except in case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Medical record review for Resident 70 was initiated on 6/17/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70's H&P examination dated 5/27/25, showed Resident 70 had the capacity to understand and make decisions. Review of Resident 70's Order Summary Report showed the following orders dated 6/3/25: - to administer oxygen via nasal cannula at 2 liters per minute, may titrate up to four liters per minute, if oxygen saturation level less than 92% every shift for acute and chronic respiratory failure with hypoxia; and, - to monitor oxygen saturation level in room air every shift. Review of Resident 70's MAR dated 6/1 to 6/18/25, showed an order dated 6/3/25, to monitor the oxygen saturation in room air every shift. The MAR also showed Resident 70 had an oxygen saturation level in room air ranging from 84% to 97%. On 6/18/25 at 0945 hours, Resident 91 was observed in his room sitting in the wheelchair at the left side of his bed. Resident 91 stated his roommate (Resident 70) was supposed to be receiving oxygen; however, Resident 70 removed his oxygen most of the time and he was wondering if that was ok for Resident 70 to remove his oxygen. On 6/18/25 at 0952 hours, during an observation and concurrent interview with Resident 70. Resident 70 was observed sitting in the wheelchair on the patio of the facility. Resident 70 was observed with portable oxygen tank at the back of his wheelchair. The oxygen tubing was observed connected to the portable oxygen tank and the portable oxygen tank was observed to be turned off. The nasal cannula was observed on the patio table and was not in Resident 70's nose. Resident 70 stated he did not need oxygen so he turned his oxygen off. Resident 70 stated he turned his oxygen off almost every day, for the most part of the day; and he was fine. On 6/18/25 at 1001 hours, an observation for Resident 70 and concurrent interview was conducted with RN 1. RN 1 verified the above observation. RN 1 was observed checking the oxygen saturation level for Resident 70 which showed 92%. RN 1 stated the facility was in the process of removing the oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 13 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. administration for Resident 70, and Resident 70 was ok without the continuous oxygen administration if Resident 70 did not want the oxygen on. RN 1 was not observed educating Resident 70 about the risks and benefits of the oxygen administration. RN 1 was observed further assisting Resident 70 to administer the continuous oxygen at 2 liters per minute. On 6/18/25 at 1005 hours, an interview and concurrent medical record review for Resident 70 was conducted with RN 1. RN 1 verified the physician's order for the oxygen and stated Resident 70 had an order for continuous oxygen administration. RN 1 also verified Resident 70's oxygen saturation level in room air was ranging from 84% to 97%. RN 1 further stated Resident 70 should have received continuous oxygen administration. On 6/18/25 at 1304 hours, an interview and concurrent medical record review for Resident 70 was conducted with the DON. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 14 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility's P&P review, the facility failed to provide the adequate and appropriate pain management for one of one final sampled resident reviewed for pain management (Resident 49). Residents Affected - Few * The facility failed to ensure an accurate pain level was assessed and documented prior to the administration of the pain medication for Resident 49. * The facility failed to ensure non-pharmacological interventions were provided prior to the administration of the pain medication for Resident 49. These failures had the potential for Resident 49 to not receive the appropriate pain management. Findings: Review of the facility's P&P titled Pain Management dated 3/17/25, showed the facility will use pain assessment tool, which is appropriate for Resident's cognitive status, to assist staff in consistent assessment of a resident's pain. Under the section pain management and treatment showed non-pharmacological intervention will include but are not limited to: - Environmental comfort measures (e.g., adjusting room temperature, smoothing linens, comfortable seating, assistive devices or pressure redistributing mattress and positioning) - Loosening any constrictive bandage, clothing or device. - Applying splinting for example (e.g., pillow or folded blanket). - Physical modalities (e.g., cold compress, warm shower bath, message, turning and repositioning). - Exercises to address stiffness and prevent contractors as well as restorative nursing program to maintain joint mobility. - Cognitive/behavioral interventions (e.g., music, relaxation, technique, activities, diversion, spiritual and comfort support, teaching the resident coping techniques and education about pain) a. Medical record review for Resident 49 was initiated on 6/17/25. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's MDS assessment dated [DATE], showed Resident 49 had moderate cognitive impairment. Review of Resident 49's Order Summary Report showed a physician's order dated 6/16/25, for tramadol HCL (pain medication) oral tablet 50 mg one tablet by mouth every six hours as needed for moderate to severe pain. Review of Resident 49's MAR dated 6/1 to 6/30/25, showed an order dated 6/16/25, for tramadol 50 mg one tablet by mouth as needed for moderate to severe pain. The MAR showed Resident 49 received the above medication on 6/17/25 at 0846 hours, and the pain level was 0 (on a pain scale of 0 to 10, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 15 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 with 0 which meant no pain, and 10 which meant the worst possible pain). Level of Harm - Minimal harm or potential for actual harm Further review of Resident 49's medical record failed to show if the pain level was assessed and accurately documented prior to the administration of the above pain medication. Residents Affected - Few b. Review of Resident 49's Physician's Order dated 2/26/25, showed an order for tramadol 50 mg one tablet by mouth every six hours as needed for moderate to severe pain. Review of Resident 49's MAR dated 6/1 to 6/30/25, showed an order dated 2/26/25, for tramadol 50 mg one tablet by mouth as needed for moderate to severe pain. The above physician's order for tramadol was discontinued on 6/16/25. Further review of Resident 49's MAR showed the medication was administered on the following dates and times with documented pain level: - on 6/1/25 at 0831 hours, for a pain level of 5; and at 1641 hours, for a pain level of 6; - on 6/5/25 at 0824 hours, for a pain level of 7; - on 6/5/25 at 0442 and 1200 hours, for a pain level of 7; - on 6/9/25 at 0400 hours, for a pain level of 8; - on 6/10/25 at 0857 hours, for a pain level of 7; - on 6/14/25 at 0913 hours, for a pain level of 7; and, - on 6/15/25 at 1015 hours. for a pain level of 7. Further review of Resident 49's MAR failed to show if non-pharmacological interventions were provided to the resident prior to the administration of the pain medication for the above dates and times. On 6/18/25 at 1009 hours, an interview and concurrent medical record review for Resident 49 was conducted with RN 1. RN 1 stated moderate to severe pain meant for pain level of 4-10, on a pain scale of 0 to 10, with 0 meant no pain and 10 meant the worst possible pain. RN 1 verified the above findings and stated the staff should have assessed and documented the accurate pain level prior to the administration of pain medication to Resident 49 on 6/17/25 at 0846 hours. In addition, RN 1 stated the staff should have provided non-pharmacological interventions prior to the administration of the pain medication to Resident 49 for the above dates and times. On 6/18/25 at 1304 hours, an interview and concurrent medical record review for Resident 49 was conducted with the DON. The DON verified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 16 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review for Resident 50 was initiated on 6/16/25. Resident 50 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 50's Order Summary Report showed a physician's order dated 1/3/24, for insulin glargine 23 units to be administered by subcutaneous injection at bedtime for diabetes. Review of Resident 50's Location of Administration Report for the months of May and June 2025, showed Resident 50's insulin injections sites were not rotated on the following dates and times: - On 5/7/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/8/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/9/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/13/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/14/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/29/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/30/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 6/5/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 6/6/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 6/7/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 6/8/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. On 6/19/25 at 0910 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 50's insulin injection sites were not rotated on the above listed dates and times. RN 1 stated the injection sites should have been rotated to prevent lipohypertrophy and skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 17 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 discomfort. Level of Harm - Minimal harm or potential for actual harm 3. Medical record review for Resident 59 was initiated on 6/17/25. Resident 59 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 59's Order Summary Report dated 6/18/25, showed a physician's order dated 5/30/25, to administer insulin lispro injection as per sliding scale if the blood sugar level result was 151 to 200 mg/dl, 2 units of insulin subcutaneously before meals and at bedtime. If blood sugar below 70 mg/dl, to follow hypoglycemic protocol. Another physician's order dated 5/28/25, showed to administer lantus (long acting) insulin 5 units subcutaneously at bedtime for DM. Review of Resident 59's Location of Administration Report for May and June 2025 for Resident 59's insulin medication injection showed the injection sites were not rotated on the following dates and times: - on 5/28/25 at 2046 hours, the lantus insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/29/25 at 2100 hours, the lantus insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/30/25 at 0648 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/30/25 at 1645 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/30/25 at 2100 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/2/25 at 2039 hours, the lantus insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/3/25 at 2053 hours, the lantus insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/4/25 at 2143 hours, the lantus insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/5/25 at 2026 hours, the lantus insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/16/25 at 2025 hours, the lantus insulin medication was administered subcutaneously to the left upper quadrant of the abdomen. - on 6/17/25 at 2111 hours, the lantus insulin medication was administered subcutaneously to the left upper quadrant of the abdomen. - on 6/4/25 at 1628 hours, the insulin lispro medication was administered subcutaneously to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 18 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 right lower quadrant of the abdomen. Level of Harm - Minimal harm or potential for actual harm - on 6/4/25 at 2143 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. Residents Affected - Few - on 6/8/25 at 1623 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/8/25 at 2034 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/11/25 at 1228 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/11/25 at 1713 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 6/11/25 at 2130 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant of the abdomen. 4. Medical record review for Resident 82 was initiated on 6/18/25. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Order Summary Report dated 6/18/25, showed a physician's order dated 2/9/25, to administer insulin glargine (long acting) subcutaneously 15 units every 12 hours for DM. Review of Resident 82's Location of Administration Report for May and June 2025 for Resident 82's insulin medication injection showed the injection sites were not rotated on the following dates and times: - on 5/2/25 at 0930 hours, the glargine insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/2/25 at 2059 hours, the glargine insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/3/25 at 1002 hours, the glargine insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/8/25 at 0822 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 5/8/25 at 2052 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 5/9/25 at 0828 hours, the glargine insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/9/25 at 2048 hours, the glargine insulin medication was administered subcutaneously to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 19 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 right lower quadrant of the abdomen. Level of Harm - Minimal harm or potential for actual harm - on 5/16/25 at 2027 hours, the glargine insulin medication was administered subcutaneously to the left upper quadrant of the abdomen. Residents Affected - Few - on 5/17/25 at 1017 hours, the glargine insulin medication was administered subcutaneously to the left upper quadrant of the abdomen. - on 5/23/25 at 1339 hours, the glargine insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/23/25 at 2058 hours, the glargine insulin medication was administered subcutaneously to the right lower quadrant of the abdomen. - on 5/24/25 at 2101 hours, the glargine insulin medication was administered subcutaneously to the left upper quadrant of the abdomen. - on 5/25/25 at 0933 hours, the glargine insulin medication was administered subcutaneously to the left upper quadrant of the abdomen. - on 6/4/25 at 0820 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/4/25 at 2047 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/5/25 at 0904 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/5/25 at 2019 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/17/25 at 0813 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. - on 6/17/25 at 2215 hours, the glargine insulin medication was administered subcutaneously to the left lower quadrant of the abdomen. On 6/18/25 at 1333 hours, an interview and concurrent medical record review for Residents 59 and 82 was conducted with LVN 4. LVN 4 verified Residents 59 and 82 were receiving insulin injections. LVN 4 was asked about things to remember when administering the medications subcutaneously. LVN 4 stated the licensed nurses needed to rotate the injection sites to prevent any complications such as non-absorption of the insulin when administered on the same site. LVN 4 was asked to review the location of administration for insulin injections for Residents 59 and 82 in the MARs for May and June 2025. LVN 4 verified the insulin injections sites were not rotated. LVN 4 acknowledged and stated the injection sites for the insulin administration should have been rotated to prevent any complication. On 6/19/25 at 1612 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 20 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs as evidenced by: * The facility failed to ensure the injection sites for the subcutaneous medication administration for four of 19 final sampled residents (Resident 49, 52, 59, and 82) and one nonsampled resident (Resident 50) were rotated consistently. This failure had the potential to negatively affect the residents' health condition and well-being. * The facility failed to ensure the emergency kit for intravenous medications and oral medications were refilled replaced within 72 hours as per the facility's P&P. This failure had the potential for negative health outcomes for residents who needed medications from the emergency kits. Findings: 1. According to the FDA Highlights of Prescribing Information for Lantus (long-acting insulin) revised 5/2019, under Dosage and Administration, showed to rotate injection sites to reduce the risk of lipodystrophy (the loss of local fat deposits as a complication of repeated insulin injections into the same subcutaneous tissue). Medical record review for Resident 52 was initiated on 6/16/25. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 10/23/24, showed Resident 52 had no capacity to understand and make medical decisions. Review of Resident 52's Order Summary Report dated 6/19/25, showed a physician's order dated 1/1/25, to administer Lantus SoloStar subcutaneous solution pen-injector 100 unit/ml (insulin glargine) 15 units subcutaneously in the evening for diabetes mellitus. Review of Resident 52's Medication Administration Records for May and June 2025 showed Resident 52 was administered the Lantus insulin daily from 5/1/25 through 6/18/25, and the injection sites used to administer the insulin injections were not consistently rotated. For example, Resident 52 received the Lantus insulin at the same site on the left arm on the following dates: - from 5/1 through 6/13/25 at 2000 hours - on 6/15 and 6/16/25 at 2000 hours 2. Medical record review for Resident 49 was initiated on 6/16/25. Resident 49 was readmitted to the facility on [DATE]. Review of Resident 49's H&P examination dated 2/26/25, showed Resident 49 did not have the capacity to understand and make medical decisions. Review of Resident 49's Order Summary Report dated 6/19/25, showed a physician's order dated 3/5/25, to administer Lantus subcutaneous solution 100 unit/ml (insulin glargine) 15 units subcutaneously at bedtime for diabetes mellitus. Review of Resident 49's Medication Administration Records for May and June 2025 showed Resident 49 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 21 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm was administered the Lantus insulin daily from 5/1/25 through 6/18/25, and the injection sites used to administer the insulin injections were not consistently rotated. For example, Resident 49 received the Lantus insulin at the same site as follows: - on 5/1 and 5/2/25 at 2100 hours, the insulin was injected into the right arm; Residents Affected - Few - from 5/3 to 5/7/25 at 2100 hours, the insulin was injected into the left arm; - from 5/12 to 5/14/25 at 2100 hours, the insulin was injected into the right arm; - on 5/18 and 5/19/25 at 2100 hours, the insulin was injected into the right arm; - on 5/20 and 5/21/25 at 2100 hours, the insulin was injected into the left arm; - on 5/24 and 5/25/25 at 2100 hours, the insulin was injected into the right arm; - on 5/30 and 5/31/25 at 2100 hours, the insulin was injected into the left arm; - on 6/1 and 6/2/25 at 2100 hours, the insulin was injected into the left arm; - on 6/4 and 6/5/25 at 2100 hours, the insulin was injected into the left arm; and - from 6/13 to 6/16/25 at 2100 hours, the insulin was injected into the left arm. On 6/19/25 at 0902 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the insulin injection sites were not rotated for Residents 49 and 52. RN 1 stated they rotated the administration sites for the insulin based on the previous shift and would choose a different site. RN 1 stated they rotated the sites to prevent lipohypertophy (a skin condition where fat or scar tissue forms under the skin due to repeated injections in the same area. This condition can affect the absorption of insulin). 5. Review of the facility's P&P titled Medication Ordering and receiving from Pharmacy revised on 8/2014 showed in part, the following: L. Before reporting duty, the charge nurse indicates the opened status of emergency kit at the shift change report. M. If exchanging kits, when the replacement kit arrives, the receiving nurse gives the used kit to the courier for return to the pharmacy. N. If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. O. The kits are checked by a pharmacist monthly. P. The Quality Assessment and Assurance Committee and provider pharmacy is responsible for establishing the list of medications to be maintained in the emergency supply, in compliance with any directives from state law regarding the emergency supply. On 6/16/25 at 0944 hours, an inspection of Medication Storage Room A and concurrent interview was conducted with RN 1. RN 1 was asked for the documentation when the emergency kits for the IV and oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 22 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm medications were last opened. RN 1 showed the emergency pharmacy logs that included all the items, date and time when the items were used from the emergency kit, and the initial dose(s) of the ordered medications were used from the emergency kits (oral and IV). Review of the log showed the following: - dated 6/9/25 at 0900 hours, one bag of one liter 0.9% normal saline (type of IV fluid) was taken. Residents Affected - Few - dated 6/13/25 at 0900 hours, one tablet of an oral medication Bactrim Double Strength (antibiotic) 800/160 mg was taken. RN 1 was asked when the emergency kits for the IV and oral medications be replaced. RN 1 verified the emergency kits for the IV and oral medications should have been replaced within 72 hours after it was opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 23 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 3. Review of the facility's P&P titled Medication Storage dated 1/2025 showed outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, dispose disposed off according to procedure for medication disposal, and reorder from the pharmacy if a current order exists. On 6/17/25 at 0846 hours, an inspection of Treatment Cart A was conducted with LVN 5. Multiple packets of Dermaseptin ointments and Dermarite Boarder Gauzes, each packaged in separate plastic, were observed without the expiration date. LVN 5 verified the observation and stated multiple staff including other treatment nurses, LVNs, used Treatment Cart A. LVN 5 stated the staff should have labeled the multiple Dermaseptin ointments and Dermarite Boarder Gauzes with an expiration date when they were removed from the original box stored in the medication room. On 6/18/25 at 1304 hours, the DON was informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure for proper storage, labeling, and disposal of the medications. * The facility failed to ensure the medication cabinets were maintained in a clean and sanitary condition. * The facility failed to ensure the multidose medications were labeled with the expiration date once the medication were taken out from the original box. * The facility failed to ensure multiple packets of Dermaseptin ointment (skin protectant cream) and Dermarite Boarder Gauzes in Treatement Cart A were labeled with an expiration date. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness. Findings: Review of the facility's P&P titled Medication Storage in the facility revised on 1/2025 showed in part, the medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. N. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. O. Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. On 6/16/25 at 0944 hours, an inspection of Medication Storage Room A and concurrent interview was conducted with RN 1. Medication Storage Room A's two cabinets were observed to be dusty and with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 24 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete hanger. RN 1 acknowledged the medication storage cabinets in Medication Storage Room A should always be maintained clean and sanitary for infection prevention and control. On 6/16/25 at 1028 hours, an inspection on Medication Storage Room B and concurrent interview was conducted with RN 1. A bottle of geri-tussin (an expectorant liquid medication used to relieve chest congestion, thins and loosens mucus) was observed to have an illegible expiration date. When asked, RN 1 verified she could not read the expiration date and stated the significance of legible expiration dates on the medications was for the residents' safety and the expiration dates should be readable. Event ID: Facility ID: 555021 If continuation sheet Page 25 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's document titled Daily Spreadsheet, Korean Menu - Spring 2025 Week 1 Tuesday - Day 3, showed the following menu for Tuesday's (6/17/25) lunch for the pureed diet: - Pureed spinach doenjang soup - Pureed kimchi - Pureed dak bulgogi (Korean BBQ chicken) - Pureed steam white rice; and - Pureed stir-fried cabbage. a. Medical record review for Resident 27 was initiated on 6/16/25. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27's Order Summary Report showed a physician's order dated 9/16/24, for a regular diet pureed texture. Review of Resident 27's Nutrition Progress Note dated 6/2/25 at 1716 hours, showed Resident 27 preferred Korean food for lunch and dinner. On 6/17/25 at 1320 hours, an observation was conducted of Resident 27. Resident 27 was observed lying in bed asleep. Resident 27's lunch tray was observed on a bedside table adjacent to Resident 27's bed. Resident 27's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). On 6/17/25 at 1337 hours, an observation and concurrent interview was conducted with CNA 7. CNA 7 was observed removing Resident 27's meal tray from Resident 27's room. CNA 7 was asked the percentage of food Resident 27 had consumed for lunch. CNA 7 stated Resident 27 had consumed approximately 10% of her lunch. b. Medical record review for Resident 96 was initiated on 6/16/25. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's Order Summary Report showed a physician's order dated 5/31/25, for a heart healthy diet with pureed texture. Review of Resident 96's Nutrition Progress Note dated 6/2/25 at 1454 hours, showed Resident 96 preferred Korean food at lunch and dinner. On 6/17/25 at 1246 hours, an observation was conducted of Resident 96. Resident 96 was observed in the dining room eating lunch. Resident 96's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). Resident 96's lunch ticket showed Resident 96 preferred Korean Food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 26 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/17/25 at 1555 hours, an interview and concurrent medical record review was conducted with the DSS. The DSS verified Residents 27 preferred Korean food for lunch and dinner as indication on Resident 27's nutrition progress note dated 6/2/25 at 1716 hours. Additionally, the DSS verified Resident 96 also preferred Korean food for lunch and dinner as indicated on Resident 96's nutrition progress note dated 6/2/25 at 1454 hours. The DSS verified Residents 27 and 96 received the American pureed food for lunch, rather than Korean pureed food for lunch in accordance with the residents' food preferences. The DSS stated the cook made a mistake today and failed to prepare the Korean pureed menu. 6. On 6/16/25 at 1317 hours, a lunch meal observation and concurrent interview for Resident 40 was conducted. Resident 40 was observed in her room eating her lunch. Resident 40's food plate was observed with chopped cooked carrots. Resident 40 did not eat the carrots that were served with the meal. Resident 40 stated her skin got itchy when she ate carrots and which was why she did not like the carrots. Medical record review for Resident 40 was initiated on 6/17/25. Resident 40 was admitted to the facility on [DATE]. On 6/16/25 at 1321 hours, an observation and concurrent interview with LVN 6 was conducted in Resident 40's room. LVN 6 verified Resident 40's meal tray was with cooked carrots and served to Resident 40. Review of the facility's menu served for the day was provided by the DSS. However, menu did not show the carrots were included for the lunch meal of the residents for the day. On 6/16/25 at 1534 hours, an interview and concurrent facility document review for Resident 40 was conducted with the DSS. The DSS verified the lunch menu for the day. The DSS was asked if the carrots were part of the lunch menu for the day. The DSS verified there were no carrots on the menu for the day. The DSS was asked why Resident 40 was served with carrots for the lunch meal. The DSS stated the cook made a mistake. The DSS further stated the food trays were not checked for accuracy before coming out from the kitchen. On 6/19/25 at 1612 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F806, sample #4. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 87 of 89 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus were not followed. * The facility failed to ensure Resident 65 received the pureed green beans as per the menu. * The facility failed to ensure the kitchen staff served the correct portion sizes as per the menu and menu spreadsheet. * The facility failed to prepare the Korean menu puree and failed to serve the Korean menu puree to the residents who preferred to eat Korean food. * The facility failed to provide the American menu for Resident 79 when she was served pureed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 27 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 kimchi instead of pureed bread. Level of Harm - Minimal harm or potential for actual harm * The facility failed to prepare the Korean menu puree and failed to serve the Korean menu puree for two nonsampled residents (Residents 27 and 96) who preferred to eat Korean food. Residents Affected - Some * The facility failed to ensure the menus were followed. Resident 40 was served with carrots not included in the menu for the day. These failures had the potential for the residents' nutritional needs not being met. Findings: Review of the facility's document titled Diet Type Report dated 6/16/25, showed 87 of 89 residents in the facility received food prepared in the kitchen. The Diet Type Report showed 20 of the 87 residents received a pureed diet. Review of the facility's document titled Resident Diet Information dated 6/19/25, showed 14 of the 20 residents in the facility were on a pureed diet and preferred the Korean menu. Review of the facility's P&P titled Standardized Menus revised 12/2022 showed the facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, standardized cycle menus are planned in advance and utilized. 1. Review of the facility's document titled Daily Spreadsheet, Parsley - Spring 2025 Week 1 Monday - Day 2, showed the following menu for Monday lunch for the pureed diet: - Pureed baked chicken; - Pureed potatos O'Brien; - Pureed whole green beans; and - One soft puree or slurry of bread or roll with margarine or butter. On 6/16/25 at 1237 hours, during the dining observation, Resident 65 was observed in the dining room with her lunch meal in front of her with RNA 2 providing assistance with the resident's feeding. Resident 65's meal tray was observed without the pureed whole green beans. Resident 65's meal ticket showed the resident was to be served a pureed diet and did not indicate Resident 65 should not receive the pureed green beans as per the menu. RNA 2 verified Resident 65 did not receive the pureed green beans. On 6/16/25 at 1242 hours, the DSS was summoned to the dining room and observed Resident 65's meal. The DSS verified the findings and stated she would need to ask the cook about the green beans and proceeded to leave. The DSS shortly came back to the dining room and provided Resident 65 a portion of pureed green beans. 2. Review of the facility's document titled Daily Spreadsheet, Korean Menu - Spring 2025 Week 1 Tuesday Day 3, showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 28 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 - Dak bulgogi (Korean BBQ chicken) regular portion, 2 oz (1/4 cup); Level of Harm - Minimal harm or potential for actual harm - Stir fried cabbage regular portion, to be served with a #8 scoop. Residents Affected - Some On 6/17/25 at 1145 hours, during the lunch tray line observation, the Lead [NAME] used a #8 scoop (1/2 cup) to serve the dak bulgogi regular portion. [NAME] 2 was observed to use a #12 scoop (1/3 cup) serving the stir fried cabbage regular portion. On 6/17/25 at 1315 hours, a concurrent observation and interview was conducted with the DSS. The DSS was informed and acknowledged the incorrect portion sizes were served for the dak bulgogi and stir fried cabbage regular portions. 3. Review of the facility's document titled Daily Spreadsheet, Korean Menu - Spring 2025 Week 1 Tuesday Day 3, showed the following menu for Tuesday lunch for the pureed diet: - Pureed spinach doenjang soup - Pureed kimchi - Pureed dak bulgogi (Korean BBQ chicken) - Pureed steam white rice; and - Pureed stir fried cabbage. On 6/17/25 at 1145 hours, a trayline observation was conducted in the kitchen. The pureed foods on the Korean menu, including the pureed dak bulgogi (Korean BBQ chicken), pureed steamed white rice, and pureed stir fried cabbage were not observed to be prepared. On 6/17/25 at 1309 hours, a concurrent observation and interview was conducted with the Lead Cook. The Lead [NAME] stated he used the American menu for all the pureed meals and verified the Korean Menu pureed items were not prepared. The Lead [NAME] stated he served a pureed bread for the American menu and a pureed kimchi for the Korean menu puree. On 6/17/25 at 1315 hours, an interview was conducted with the DSS. The DSS stated the kitchen staff were communicated the resident's preferences for American menu or Korean menu on the meal ticket. The DSS was informed and acknowledged the findings. The DSS stated she was not aware the Korean menu puree, aside from the puree kimchi, was not prepared. On 6/17/25 at 1555 hours, a follow-up interview was conducted with the DSS. When asked why the Korean menu puree was not prepared, the DSS stated the cook made a mistake. 4. Review of the facility's document titled Daily Spreadsheet, Parsley - Spring 2025 Week 1 Tuesday - Day 3, showed the following menu for Tuesday lunch for the pureed diet: - Pureed Dijon pork cutlet; - Pureed orzo with vegetables; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 29 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 - Pureed seasoned beets; and Level of Harm - Minimal harm or potential for actual harm - Soft puree or slurry, one bread or roll with margarine or butter. Residents Affected - Some On 6/17/25 at 1232 hours, an observation of the lunch meal service was conducted in the facility's dining room. Resident 79's meal tray was observed. Resident 79's meal ticket showed she did not have any preferences. Resident 79's meal tray was observed with the American menu puree (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets) and pureed kimchi. On 6/17/25 at 1309 hours, a concurrent observation and interview was conducted with the Lead Cook. The Lead [NAME] stated he used the American menu for all the pureed meals. The Lead [NAME] stated he served a pureed bread for the American menu and a pureed kimchi for the Korean menu puree. On 6/17/25 at 1315 hours, an interview was conducted with the DSS. The DSS stated the kitchen staff were communicated the resident's preferences for American menu or Korean menu on the meal ticket. The DSS was informed and acknowledged Resident 79 should have been served the pureed bread and not the pureed kimchi. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 30 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 27 was initiated on 6/16/25. Resident 27 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 27's Nutrition Progress Note dated 6/2/25 at 1716 hours, showed Resident 27 preferred Korean food for lunch and dinner. On 6/17/25 at 1320 hours, an observation was conducted of Resident 27. Resident 27 was observed lying in bed asleep. Resident 27's lunch tray was observed on a bedside table adjacent to Resident 27's bed. Resident 27's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). 3. Medical record review for Resident 96 was initiated on 6/16/25. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's Nutrition Progress Note dated 6/2/25 at 1454 hours, showed Resident 96 preferred Korean food at lunch and dinner. On 6/17/25 at 1246 hours, an observation was conducted of Resident 96. Resident 96 was observed in the dining room eating lunch. Resident 96's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). Resident 96's lunch ticket showed Resident 96 preferred Korean Food. On 6/17/25 at 1555 hours, an interview and concurrent medical record review was conducted with the DSS. The DSS verified Resident 27 preferred Korean food for lunch and dinner as indication on Resident 27's nutrition progress note dated 6/2/25 at 1716 hours. Additionally, the DSS verified Resident 96 also preferred Korean food for lunch and dinner as indicated on Resident 96's nutrition progress note dated 6/2/25 at 1454 hours. The DSS verified Residents 27 and 96 received American pureed food for lunch today, rather than Korean pureed food for lunch in accordance with the residents' food preferences. 4. On 6/16/25 at 1317 hours, a lunch meal observation and concurrent interview for Resident 40 was conducted. Resident 40 was observed in her room eating her lunch meal. Resident 40's food plate was observed with chopped cooked carrots. Resident 40 did not eat the carrots that were served with the meal. Review of Resident 40's meal ticket on the food tray showed Resident 40 disliked the carrots. On 6/16/25 at 1321 hours, an observation and concurrent interview with LVN 6 was conducted in Resident 40's room. LVN 6 verified Resident 40's meal tray was served with carrots. LVN 6 was asked to review Resident 40's meal ticket on the food tray. LVN 6 verified Resident 40's food preferences, and the resident disliked the carrots. On 6/16/25 at 1321 hours, the DSS was summoned to come to Resident 40's room. The DSS was asked about Resident 40's food tray. The DSS verified Resident 40 was served with the carrots and the meal ticket showed Resident 40 disliked the carrots. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 31 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/19/25 at 1612 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross refernces to F803, example #6. Based on observation, interview, and medical record review, the facility failed to ensure the food preferences were honored for six of 87 residents who received food prepared in the kitchen. * The facility failed to serve the pureed Korean menu to the residents who had a preference for Korean food (Residents 7, 16, 27, 35, and 96). * The facility failed to ensure the food preferences was honored for Resident 40. Resident 40 disliked carrots but was served with carrots on her lunch tray. These failures had the potential to negatively impact the residents' food intake and well-being. Findings: Review of the facility's document titled Diet Type Report dated 6/16/25 showed 87 of 89 residents received food prepared in the kitchen. 1. Review of the facility's document titled Daily Spreadsheet, Parsley - Spring 2025 Week 1 Tuesday - Day 3, showed the following menu for Tuesday lunch for the pureed diet: - Pureed Dijon pork cutlet; - Pureed orzo with vegetables; - Pureed seasoned beets; and - Soft puree or slurry, one bread or roll with margarine or butter. Review of the facility's document titled Daily Spreadsheet, Korean Menu - Spring 2025 Week 1 Tuesday Day 3, showed the following menu for Tuesday lunch for the pureed diet: - Pureed spinach doenjang soup - Pureed kimchi - Pureed dak bulgogi (Korean BBQ chicken) - Pureed steam white rice; and - Pureed stir fried cabbage. On 6/17/25 at 1145 hours, a trayline observation was conducted in the kitchen. The pureed foods on the Korean menu, including the pureed dak bulgogi (Korean BBQ chicken), pureed steamed white rice, and the pureed stir fried cabbage were not observed to be prepared. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 32 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm On 6/17/25 at 1232 hours, an observation of the lunch meal service was conducted in the facility's dining room. A meal cart was observed dropped off by the kitchen staff. The ADON and DSD were observed checking the trays in the meal cart. The ADON was observed checking a printout of the physician's diet orders and calling the orders out. The DSD was observed checking the resident tray's meal and meal ticket (used to identify the resident's diet and food preferences for meal service. Residents Affected - Few The following was observed during the lunch meal service: - Residents 7, 16, and 35's meal tickets were observed and showed Residents 7, 16, and 35 preferred Korean food. Residents 7, 16, and 35's meal trays were observed with the American menu puree (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets) and pureed kimchi. On 6/17/25 at 1309 hours, a concurrent observation and interview was conducted with the Lead [NAME] in the kitchen. The Lead [NAME] stated he used the American menu for all the pureed meals and verified the Korean Menu pureed items were not prepared. The Lead [NAME] stated he served a pureed bread for the American menu and a pureed kimchi for the Korean menu puree. On 6/17/25 at 1315 hours, an interview was conducted with the DSS. The DSS stated the kitchen staff were communicated the resident's preferences for American menu or Korean menu on the meal ticket. The DSS was informed and acknowledged the findings. The DSS stated she was not aware the Korean menu puree, aside from the puree kimchi, was not prepared. On 6/17/25 at 1555 hours, a follow-up interview was conducted with the DSS. When asked why the Korean menu puree was not prepared, the DSS stated the cook made a mistake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 33 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 61) observed during the dining observation task received the appropriate mechanically altered diet as ordered by the physician. This failure posed the risk of aspiration and resident's nutritional needs not being met. Findings: Review of the facility's P&P titled Therapeutic Diet Orders revised 11/2024 showed the therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietitian who has been delegated to write diet orders, to the extent allowed by state law. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) Complete IDDSI Framework Detailed definitions 2.0 dated 7/2019 for a soft and bite-sized diet (SB6), showed the food can be mashed/broken down with pressure from fork, spoon, or chopsticks and a knife is not required to cut this food. The food is also soft, tender, and moist throughout but with no separate thin liquid. Under the section titled food specific - bread, showed no regular dry bread, sandwiches or toast of any kind. On 6/16/25 at 1209 hours, a lunch meal cart was observed to be dropped off by the kitchen staff for the residents in the dining room. The ADON was observed checking a printout of the physician's diet orders and calling the orders out. The DSD was observed checking the meal and meal ticket on the residents' trays. The ADON stated they made sure the menu matched the diet orders, the texture matched, and any additional directions. On 6/16/25 at 1226 hours, Resident 61 was observed in the dining room being fed by Resident 70. Resident 61's meal ticket showed her diet order was a carbohydrate controlled soft and bite-sized diet (SB6). Resident 61's meal tray was observed with a regular texture slice of bread. On 6/16/25 at 1242 hours, an observation of Resident 61 and concurrent interview was conducted with the DSS. The DSS observed, was informed, and acknowledged the above findings. The menu spreadsheet was reviewed and the DSS acknowledged Resident 61 should not have received the regulax texture slice of the bread. Medical record review for Resident 61 was initiated on 6/16/25. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Speech Language Pathologist (SLP) Discharge summary dated [DATE], showed a soft and bite-sized diet was recommended for Resident 61. Review of Resident 61's MDS assessment dated [DATE], showed Resident 61's cognition was severely impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 34 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Review of Resident 61's Order Audit Report dated 6/18/25, showed a physician's order dated 3/7/25, for a carbohydrate controlled diet, soft and bite-sized (SB6) texture, thin liquid consistency, plate guard for all meals, bread cleared and screened by the SLP. The order details history section showed the SLP updated the original order on 6/16/25 at 1510 hours, to show on the order that bread was cleared and screened by the SLP. Residents Affected - Few On 6/18/25 at 1326 hours, an interview and concurrent medical record review for Resident 61 was conducted with the SLP. The SLP stated when she evaluated a resident and changed the diet, the change was not active until the physician's order was written. The SLP stated once she put the physician's order in their EHR, then it was considered active. The SLP was informed and acknowledged the above findings. The SLP verified she did not revise the diet order for Resident 61 until 6/16/25 at 1510 hours, to show Resident 61 was cleared to eat regular bread. The SLP verified Resident 61 should not have been served the regular bread during lunch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 35 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the foods in the kitchen were properly labeled and dated, and the expired items were thrown out. * The facility failed to ensure the kitchen utensils and equipment were clean and not worn out. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the refrigerator used to store residents' food from the outside was clean. * The facility failed to ensure the handwashing signage was posted and visible at the handwashing station in the kitchen. * Two pieces of bananas on Resident 22's bedside table were unlabeled and dated. These failures posed the risk for food borne illnesses in highly susceptible resident population of 87 facility residents who received food prepared in the kitchen. Findings: Review of the facility's document titled Diet Type Report dated 6/16/25, showed 87 of 89 residents received food prepared in the kitchen. 1. Review of the facility's P&P titled Date Marking for Food Safety revised 12/2022 showed the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or date by which the food shall be consumed or discarded. The marking system shall include the date of opening, and the date the item must be consumed or discarded or may refer to the food storage charts posted as the use by dates if manufacturer expiration dates are not present. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as Day 1. During an initial tour of the kitchen on 6/16/25 at 0755 hours, the following was observed with [NAME] 1: - one container labeled dry pasta with a prepared date of 4/15/25, and a use by date of 6/15/25; - one opened bottle of oyster sauce with a prepared date of 6/12/25, and a use by date of 6/12/28; and the manufacturer's expiration date on the bottle showed 2/27/28. The [NAME] 1 verified the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 36 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 - one container labeled kimchi with a prepared date of 5/15/25, and a use by date of 5/25/25; and Level of Harm - Minimal harm or potential for actual harm - one container labeled chopped kimchi with a prepared date of 5/15/25, and a use by date of 5/25/25. Residents Affected - Some On 6/16/25 at 0846 hours, the DSS was informed and verified the findings. The DSS stated the label was wrong and the kimchi was prepared the day prior. 2. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, for materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During an initial tour of the kitchen on 6/16/25 at 0755 hours, the following was observed with [NAME] 1: - two rubber spatulas with corroded edges; - one rubber spatula with melted handle, coating on the spatula appears brown; and - one small pitcher with a melted bottom. Cook 1 verified the findings. On 6/16/25 at 0846 hours, the DSS was informed of and acknowledged the findings. 3. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. Review of the facility's P&P titled Cutting Boards dated 2014 showed cutting boards should be replaced when the boards begin to have breaks, corrosion, open seams, cracks and chipped areas as the boards can no longer be sanitized properly. During an initial tour of the kitchen on 6/16/25 at 0755 hours, the following was observed with [NAME] 1: - Two cutting boards heavily marred with chipped areas Cook 1 verified the above findings. On 6/16/25 at 0846 hours, the DSS was informed and acknowledged the findings. 4. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 37 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/16/25 at 0819 hours, an observation of the residents' refrigerator was conducted with RN 1. There was a brown food residue observed on one of the refrigerator shelves. RN 1 verified the findings. 5. According to the USDA Food Code 2022, Section 6-301.14, Handwashing Signage, a sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees. On 6/16/25 at 0755 hours, 6/17/25 at 1145 hours, and 6/18/25 at 0848 hours, the handwashing station in the kitchen was observed without a handwashing signage posted or visible. On 6/18/25 at 0917 hours, the handwashing station was observed with the DSS. The DSS stated she had the handwashing signage but did not currently have it posted. The DSS stated it should had been posted. 6. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised on 1/30/25, showed it is the right of the residents of this facility to have food brought in by family or other visitors, however the food must be handled in a way to ensure the safety of the resident .2. All food items that are already prepared by the family or visitor brought in must be approved per Nursing to ensure is in accordance with the diet order and labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator . d. If not consumed within three days, food will be thrown away by facility staff .5. All items not maintained are subject to being discarded if not removed by the resident and/or resident representative. 6. If any part of this policy is not followed, the facility reserves the right to protect others by not allowing food items to be brought into the facility for a resident. 7. The facility staff will assist residents in accessing and consuming food that is brought in by the residents and family or visitors if the resident is not able to do so on their own. Medical record review of Resident 22 was initiated on 6/16/25. Resident 22 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 22's H&P examination dated 8/16/24, showed Resident 22 had no capacity to understand and make decisions. Review of Resident 22's Order Summary Report dated 6/17/25, showed a physician order dated 2/21/25, for regular diet soft and bite sized texture, thin consistency, patient screened and cleared for bread by speech language pathologist, gravies to meals, double protein, fortified meals for breakfast, lunch and dinner, Korean menu. On 6/16/25 at 0914 hours, an observation of Resident 22's bedside table and concurrent interview was conducted with CNA 3. Resident 22's bedside table was observed to have two pieces of bananas in a clear plastic bag that was not labeled with name, date brought and use by date. CNA 3 was asked when the bananas were brought in by the resident's visitor. CNA 3 stated she did not know since when the bananas were brought. CNA 3 verified the bananas were perishable foods and should have been at least dated when it was brought in by the resident's visitor. On 6/16/25 at 1252 hours, an interview was conducted with LVN 2. LVN 2 was informed about the two pieces of bananas in a clear plastic bag on Resident 22's bedside table. LVN 2 was asked when the two pieces of bananas were brought in by Resident 22's visitor. LVN 2 stated she did not know when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 38 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm two pieces of bananas were brought. LVN 2 verified the two pieces of bananas brought in by Resident 22's visitor should have been dated because the banana was a perishable food. On 6/19/25 at 1604 hours, an interview was conducted with the DON. The DON acknowledged the above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 39 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility's assessment dated [DATE], did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment; the resources necessary to care for the residents including weekends; and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. On 6/19/25 at 1343 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with Administrator. The Administrator verified the Facility Assessment was dated 7/8/24, and acknowledged he was not aware of the new update of the Facility Assessment from the CMS. The Administrator verified there were no direct care staff, direct care representatives, residents, resident representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there were no resources necessary to care for the residents including weekends, and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest update from the CMS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 40 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed medical record review, the facility failed to ensure the medical record was accurate, for one of three resident closed records. * The facility documented Resident 94's vital signs were obtained on 6/12/25, however, Resident 94 was not in the facility on 6/12/25, having been transferred to the acute care hospital on 6/10/25. This failure had the potentail to negative impact Resident 94's well-being as the medical record information was inaccurate. Findings: Closed medical record review for Resident 94 was initiated on 6/16/25. Resident 94 was admitted to the facility on [DATE], and transferred to Acute Care Hospital 1 on 6/10/25. Review of Resident 94's Nursing Progress Note dated 6/10/25 at 1100 hours, showed Resident 94 was transferred to Acute Care Hospital 1 for lethargy on 6/10/25. Review of Resident 94's Weights and Vital Signs dated 6/12/25 1455 hours, showed the following vital signs were obtained for Resident 94 on 6/12/25 at 1455 hours: blood pressure 146/83 mmHg, respirations 19 breaths per minute, pulse 70 beats per minute, and oxygen saturation level 96%. On 6/18/25 at 1625 hours, an interview and concurrent closed medical record was conducted with the DON. The DON verified Resident 94 was transferred to Acute Care Hospital 1 on 6/10/25, and had remained at Acute Care Hospital 1 thereafter. The DON verified Resident 94's closed medical record was inaccurate specific to the documentation of Resident 94's vital signs (blood pressure, pulse, respirations, and oxygen saturation) being obtained in the facility on 6/12/25 at 1455 hours (as Resident 94 resided in Acute Care Hospital 1 on this date and time). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 41 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/19/25 at 1129 hours, an observation of the facility's laundry room and concurrent interview was conducted with the Laundry Aide. The counter designated for clean laundry sorting was observed with clean bed linens folded and stacked on top of the counter. The Laundry Aide's cell phone charger, plastic water bottle, and water [NAME] were observed stored on the clean laundry counter adjacent to the clean resident bed linens. The Laundry Aide verified the findings and stated his personal items should not be stored adjacent to resident clean linens. Residents Affected - Few On 6/19/25 at 1133 hours, an interview was conducted with the IP. The IP stated the staff's personal items should not be stored on the residents clean laundry sorting area adjacent to the clean resident laundry, to prevent contamination of the clean residents' laundry from potentially unclean staff personal items. 2. On 6/16/25 at 1031 hours, initial tour of the facility, an observation and concurrent interview for Resident 85 was conducted with CNA 4. Resident 85 was observed sitting in his wheelchair inside his room. A posted signage was observed at Resident 85's doorway showing Resident 85 was placed on EBP, and the staff must wear a gown and gloves when providing high contact resident care such as changing incontinent briefs or assisted in transferring. Resident 85 asked CNA 4 for assistance for going back to bed. CNA 4 performed hand hygiene and donned of disposable gloves. CNA 4 assisted Resident 85 back to bed with no PPE gown was observed. On 6/16/25 at 1041 hours, an observation and concurrent interview with CNA 4 was conducted. CNA 4 was asked about Resident 85. CNA 4 verified Resident 85 was on enhanced barrier precaution (EBP), as shown on the resident's doorway posted signage. CNA 4 was asked when she assisted Resident 85 in the room. CNA 4 verified and acknowledged she performed hand hygiene and put on gloves but did not put a gown per EBP protocol. On 6/16/25 at 1056 hours, an interview for Resident 85 was conducted with LVN 6. LVN 6 verified Resident 85 was on enhanced barrier precaution. LVN 6 verified and stated the staff should wear the PPE first before providing care to the resident such as changing linens, providing hygiene and transferring the resident. Medical record review for Resident 85 was initiated on 6/17/25. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's Order Summary Report dated 6/17/25, showed a physician's order dated 4/30/25 to place Resident 85 on an EBP related to urostomy. Review of Resident 85's Plan of Care showed a care plan problem dated 4/30/25, addressing the enhance barrier precaution. The interventions included to apply EBP to prevent the spread of infection for specific care activities. On 6/18/25 at 1318 hours, an interview for Resident 85 was conducted with the IP. The IP was asked about the facility's process about the EBP. The IP stated they placed the residents who had a central lines, urinary catheters, and other devices placed inside the resident's body on EBP. The IP stated the staff would put on PPE when providing a closed contact care such as transferring, changing diapers and if expecting a splash, they must wear a face shield. The IP was informed of the observation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 42 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm when CNA 4 assisted Resident 85 in an EBP room not wearing a PPE gown for transferring the resident back to bed. The IP stated CNA 4 should have been wearing a PPE gown for providing care to the resident. On 6/19/25 at 1612 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Residents Affected - Few Based on observation, interview, medical record review, and P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility staff failed to ensure hand hygiene was performed in between changing of gloves during the medication pass administration on Resident 52 with GT feeding. * The facility failed to ensure CNA 4 followed the enhanced barrier precaution for Resident 85 when assisting the resident back to bed. * The facility failed to ensure the Laundry Aide did not store his personal items adjacent to resident clean linens in the laundry sorting area. These failures posed the risk for the transmission of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Hand Hygiene revised 12/19/22, showed the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Medical record review of Resident 52 was initiated on 6/18/25. Resident 52 was admitted on [DATE]. Review of Resident 52's H&P examination dated 10/23/24 showed Resident 52 had no capacity to understand and make decisions. Review of Resident 52's Order Summary Report dated 6/18/25, showed the following physician's orders: - dated 1/30/25, for enhanced barrier precaution related to G-tube every shift. - dated 6/4/25, for enteral feed order every shift for G-tube feeding. Continuous enteral feeding: formula: Glucerna 1.2 (enteral feeding formula) rate 70 ml/hr x 20 =1400 ml/24 hours, 84 grams protein, 1134 ml free water. Start at 12 PM and stop at 8 AM, may run until full dose is completed. On 6/18/25 at 0842 hours, an observation was conducted with LVN 1 during the medication pass administration for Resident 52 with a G-tube feeding. LVN 1 was observed to not perform hand hygiene in between the changing of the gloves on the following situations: - LVN 1 failed to perform hand hygiene after removing his gloves, proceeded to touch the edge of the bed to check the wiring, then wore his gloves and turned off the G-tube machine of Resident 52 and proceeded to check G-tube placement of Resident 52. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 43 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - LVN 1 removed his gloves to get spoons from the medication cart, then when LVN 1 got spoons from the medication cart, LVN 1 proceeded to wear new set of disposable gloves without performing hand hygiene. On 6/18/25 at 1034 hours, an interview was conducted with LVN 2. LVN 2 was informed he missed to perform hand hygiene in between changing of the gloves. LVN 2 verified he should have performed hand hygiene On 6/19/25 at 1604 hours, an interview was conducted with the DON. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 44 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to offer PCV15 or PCV 20 vaccination to one of five final sampled residents (Resident 23) reviewed for immunizations. Residents Affected - Few * Resident 23 received the PPSV23 vaccine on 12/5/13, however, the facility failed to offer Resident 23 PCV15 or PCV 20 vaccination, in accordance with the facility's P&P and CDC's recommendations. This failure increased the resident's risk for being inadequately vaccinated for the pneumococcal disease and its associated complications. Findings: Review of the CDC's guidelines for pneumococcal vaccination showed adults aged 65 years and older, who had only received PPSV23 vaccination (regardless of risk conditions) are to receive one dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. Review of the facility's P&P titled Pneumococcal Vaccine Series dated 12/19/22, showed it is the facility's policy to offer residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: For adults 65 years or older who have only received PPSV23: Give one dose PCV15 or PCV 20. The PCV 15 or PCV 20 dose should be administered at least one year after the most recent PPSV23 vaccination. Medical record review for Resident 23 was initiated on 6/16/25. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23 admission record dated 6/19/25, showed Resident 23 was [AGE] years of age. Review of Resident 23's Pneumococcal Vaccine Consent Form dated 6/11/23, showed Resident 23's responsible party declined to give consent for the pneumococcal vaccine, as Resident 23 had received a pneumococcal vaccine (PPSV23) in 2013. Review of Resident 23's California Immunization Registry (CAIR) dated 6/19/25, showed Resident 23 received the PPSV23 vaccine on 12/5/13. The CAIR immunization record failed to show Resident 23 had received the PCV 15 or PCV 20 vaccine. Review of Resident 23's facility Immunization Report dated 6/18/25, failed to show Resident 23 had received the PCV 15 or PCV 20 vaccine. On 6/19/25 at 1445 hours, an interview and concurrent medical record review was conducted with the IP. The IP reviewed Resident 23's medial record and verified Resident 23's medical record and CAIR immunization record failed to show Resident 23 had received the PCV 15 or PCV 20 vaccine in accordance with the facility's P&P and CDC recommendations (for Resident 23's age group and immunization history). The IP stated he would follow up with Resident 23's responsible party to determine if Resident 23's responsible party would consent for Resident 23 receiving the PCV 15 or PCV 20 vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 45 of 45