Health inspection·December 14, 2022

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 89's Informed Consent form for Ativan 1 mg every eight hours PRN for anxiety showed the following: - The resident/resident's representative listed below had given the informed consent to treat. - Resident 89's name was listed on the form, but there was no responsible party listed, no facility staff's signature, no physician's signature, and no date. Event ID: Facility ID: 555035 If continuation sheet Page 2 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review, the facility failed to provide the reasonable accommodation to meet the needs of two of 25 final sampled residents (Residents 17 and 359) and two nonsampled residents (Residents 61 and 360). The facility failed to ensure the residents' call lights were within reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care. Residents Affected - Few Findings: 1. On 12/7/22 at 0829 hours, Resident 17 was observed in bed, awake. The call light was observed on the floor, and not within the resident's reach. On 12/7/22 at 0831 hours, the ADON was asked to go to Resident 17's room. The ADON observed Resident 17's call light on the floor and acknowledged the resident could not reach it. On 12/8/22 at 0922 hours, an observation and interview was conducted with Resident 17. Resident 17 was observed in bed, awake. The call light was observed hanging on the side rail. Resident 17 stated she needed her call light, but the staff took her call light away. Resident 17 further stated even if she pressed the call light button, the staff would not respond to the call light. On 12/8/22 at 0928 hours, the IP was asked to go to Resident 17's room. The IP observed Resident 17's call light was hanging on the side rail and acknowledged the resident could not reach it. 2. On 12/7/22 at 0840 hours, Resident 61 was observed in bed, asleep. The call light cord was wrapped around the side rail, and the call light button was not within the resident's reach. On 12/7/22 at 0842 hours, the ADON asked to go to Resident 61's room. The ADON observed Resident 61's call light cord was wrapped around the side rail and acknowledged the resident could not reach the call light. 3. On 12/7/22 at 0910 hours, Resident 360 was observed in bed, asleep. The call light was observed on the floor, and not within the resident's reach. On 12/7/22 at 0913 hours, the ADON asked to go to Resident 360's room. The ADON observed Resident 360's call light was on the floor and acknowledged the resident could not reach it. 4. On 12/7/22 at 0918 hours, Resident 359 was observed in bed, awake. The call light was observed on the floor, and not within the resident's reach. On 12/7/22 at 0929 hours, CNA 3 was asked to go to Resident 359's room. The CNA 3 observed Resident 359's call light on the floor and acknowledged the resident could not reach it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 3 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 25 final sampled residents' (Resident 34) advance directive was in the medical record. This failure put Resident 34 at risk of not receiving the medical treatment or medical services in accordance with his wishes. Findings: Medical record review for Resident 34 was initiated on 12/7/22. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 34's History and Physical Examination dated 8/11/22, showed Resident 34 did not have the capacity to understand, make decisions, and was listed as a surrogate decisionmaker. Review of Resident 34's Advance Directive Acknowledgement form dated 10/25/21, showed Resident 34 had executed an advance directive on 12/6/05. Review of Resident 34's Physician Orders for Life-Sustaining Treatment (POLST) dated 3/10/20, showed Resident 34's advance directive was available and reviewed. However, the advance directive was not in the medical record. On 12/8/22 at 1423 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 reviewed Resident 34's medical record and verified Resident 34's advance directive was not in the medical record. On 12/8/22 at 1436 hours, an interview was conducted with the SSD. The SSD stated during admission of a resident to the facility, they would ask whether the resident had an advance directive and if the resident had an advance directive, a copy of the advance directive would be placed in the medical record. On 12/8/22 at 1440 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director was asked to provide a copy of Resident 34's advance directive. The Medical Records Director reviewed Resident 34's medical record and was unable to find a copy of Resident 34's advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 4 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the visual privacy for one nonsampled resident (Resident 408) was provided during care. This had the potential to violate the resident's rights to privacy. Residents Affected - Few Findings: On 12/7/22 at 0824 hours, LVN 1 was observed administering the medications to Resident 408 via GT. Resident 408 occupied the last bed of a room shared with another resident. Resident 408's abdomen and upper body were exposed during the medication administration. Resident 408's privacy curtain was partially drawn, leaving Resident 408 visible to other residents and staff. On 12/7/22 at 0830 hours, an interview was conducted with LVN 1. LVN 1 verified the findings and stated the privacy curtain should have been fully closed during care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 5 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0636 Level of Harm - Potential for minimal harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDSs for annual assessments were completed within 14 calendar days of the ARDs for three nonsampled residents (Residents 45, 68, and 78). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments once the health problems had been identified. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019 showed a comprehensive MDS assessment (annual and significant change) and non-comprehensive assessment (quarterly and discharge) completion date must be no later than 14 calendar days of the assessment's ARD. Review of the MDSs for Residents 45, 68, and 78 was initiated on 12/9/22. The MDSs for Residents 45, 68, and 78 showed the following: 1. Resident 45's MDS for annual assessment dated [DATE], was still in progress and not completed. The annual assessment should be completed on 11/9/22. 2. Resident 68's MDS for annual assessment dated [DATE], was still in progress and not completed. The annual assessment should be completed on 11/4/22. 3. Resident 78's MDS for annual assessment dated [DATE], was still in progress and not completed. The annual assessment should be completed on 11/2/22. On 12/9/22 at 0858 hours, an interview and concurrent medical record review for Residents 45, 68, and 78 was conducted with the MDS Coordinator. The MDS Coordinator verified above findings and stated the MDS for annual assessments must be completed within14 calendar days of the ARD. The MDS Coordinator stated the reason for the MDS assessments being late was there was a staffing issue in the MDS department when she was on leave. The MDS Coordinator was an LVN. The MDS Coordinator further stated she could not sign to complete the MDS assessments due to the requirement of the RN's signature. The MDS assessments were not signed timely because the MDS Coordinator must wait for the RN MDS nurse or MDS consultant to sign the completion of the MDS assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 6 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDSs for quarterly assessments were completed within 14 calendar days of the ARDs for five of 25 final sampled residents (Residents 12, 30, 37, 62, and 93) and 14 nonsampled residents (Residents 1, 4, 5, 18, 24, 32, 36, 38, 46, 53, 61, 63, 70, and 72). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments once the health problems had been identified. Residents Affected - Some Findings: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019, showed a comprehensive MDS assessment (annual and significant change) and non-comprehensive assessment (quarterly and discharge) completion date must be no later than 14 calendar days of the assessment's ARD. Review of the MDSs for Residents 1, 4, 5, 12, 18, 24, 30, 32, 36, 37, 38, 46, 53, 61, 62, 63, 70, 72, and 93 was initiated on 12/9/22. The MDSs for Residents 1, 4, 5, 12, 18, 24, 30, 32, 36, 37, 38, 46, 53, 61, 62, 63, 70, 72, and 93 showed the following: * Resident 1's MDS for quarterly assessment dated [DATE], was completed on 12/5/22, more than 14 days of the ARD. * Resident 4's MDS for quarterly assessment dated [DATE], was completed on 11/30/22, more than 14 days of the ARD. * Resident 5's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 days of the ARD. * Resident 12's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 days of the ARD. * Resident 18's MDS for quarterly assessment dated [DATE], was completed on 12/7/22, more than 14 days of the ARD. * Resident 24's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 days of the ARD. * Resident 30's MDS for quarterly assessment dated [DATE], was completed on 11/28/22, more than 14 days of the ARD. * Resident 32's MDS for quarterly assessment dated [DATE], was completed on 12/7/22, more than 14 days of the ARD. * Resident 36's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 days of the ARD. * Resident 37's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 7 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0638 days of the ARD. Level of Harm - Potential for minimal harm * Resident 38's MDS for quarterly assessment dated [DATE], was completed on 12/1/22 or more than 14 days of the ARD. Residents Affected - Some * Resident 46's MDS for quarterly assessment dated [DATE], was completed on 11/29/22, more than 14 days of the ARD. * Resident 53's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 days of the ARD. * Resident 61's MDS for quarterly assessment dated [DATE], was completed on 11/30/22, more than 14 days of the ARD. * Resident 62's MDS for quarterly assessment dated [DATE], was completion date of 10/27/22, more than 14 days of the ARD. * Resident 63's MDS for quarterly assessment dated [DATE], was completed on 11/29/22, more than 14 days of the ARD. * Resident 70's MDS for quarterly assessment dated [DATE], was completed on 12/5/22, more than 14 days of the ARD. * Resident 72's MDS for quarterly assessment dated [DATE], was completed on 12/8/22, more than 14 days of the ARD. * Resident 93's MDS for quarterly assessment dated [DATE], was completed on 12/6/22, more than 14 days of the ARD. On 12/9/22 at 0858 hours, an interview and concurrent medical record review for all the residents listed above was conducted with the MDS Coordinator. The MDS Coordinator verified above findings and stated the MDSs for quarterly assessments must be completed within 14 calendar days after the MDS assessments' ARD. The MDS Coordinator stated the reason for the MDS assessments being late was there was a staffing issue in the MDS department when she was on leave. The MDS Coordinator was an LVN. The MDS Coordinator further stated she could not sign to complete the MDS assessments due to the requirement of the RN signature. The MDS assessments were not sign timely because the MDS Coordinator must wait for the RN MDS nurse or MDS consultant to sign the completion of the MDS assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 8 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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** 2. On 12/7/22 at 1027 hours, during an initial tour of the facility, Resident 26 was observed in bed with bilateral side rails elevated. Subsequent observations showed on 12/8/22 at 1153 hours and 12/8/22 at 1344 hours, Resident 26 in bed with bilateral side rails elevated. On 12/14/22 at 1103 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 26's bedside. LVN 5 verified Resident 26 was in bed with bilateral 1/4 side rails elevated. Medical record review for Resident 26 was initiated on 12/7/22. Resident 26 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed an order dated 7/31/18, for bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated HOB (head of bed) for management and provision of enteral feeding (intake of food via the gastrointestinal [GI] tract). Review of Resident 26's plan of care failed to show a care plan problem for side rail use. On 12/14/22 at 1104 hours, an interview and concurrent medical record review for was conducted with RN 1. RN 1 was asked to show Resident 26's care plan for the use of side rails. RN 1 showed a care plan problem dated 12/14/22, for the use of side rails as a non-restraint. RN 1 stated she added a care plan problem for the use of side rails for Resident 26 today. RN 1 verified there was no care plan problem in place prior to the use of bilateral side rails for Resident 26. Cross reference to F700, example #1. Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the plans of care to reflect the individual care needs for three of 25 final sampled residents (Residents 26, 48, and 59). * The facility failed to develop a care plan problem to address Residents 26 and 48's use of side rails. * The facility failed to develop a care plan problem for Resident 59's Caplyta (medication used to treat schizophrenia). These posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: Review of the facility's P&P titled Side Rail Use When Not a Restraint (undated) showed to complete a care plan entry when side rails are used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 9 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 1. On 12/7/22 at 0845 and 1127 hours, and on 12/13/22 at 0831 and 0939 hours, Resident 48 was observed lying in bed with bilateral side rails elevated by the head of the bed. Medical record review for Resident 48 was initiated on 12/7/22. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE]. Residents Affected - Few Review of Resident 48's History and Physical examination dated 11/22/22, showed Resident 48 had diagnoses including spastic recurrent seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Review of Resident 48's plan of care failed to show a care plan problem was developed to address the use of side rails. On 12/13/22 at 0949 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above information. RN 1 verified a care plan problem was not developed to address Resident 48's use of side rails but should have been. Cross reference to F700, example #3. 3. Resident 59's medical record review was initiated on 12/7/22. Resident 59 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 59's Order Summary Report showed the physician's order to administer Caplyta capsule 42 mg one capsule by mouth one time a day. Review of Resident 59's care plan showed no care plan problem was developed to address the use of Caplyta. On 12/9/22 at 0953 hours, an interview and concurrent medical record review was conducted with RN 2. When asked if Resident 59 had a care plan for the Caplyta medication, RN 2 stated there was no care plan developed for Resident 59's Caplyta medication use. On 12/14/22 at 0933 hours, an interview and concurrent medical record review was conducted with the ADON. When asked if Resident 59 had a care plan for Caplyta medication use before 12/9/22, the ADON stated no care plan had been developed for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 10 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide an ongoing in room activity program to meet the needs and interests of two of 25 final sampled residents (Residents 12 and 76). Residents Affected - Few * Resident 12 was assessed to prefer watching television. However, Resident 12 was provided a television with a blurry display. * Resident 76 was assessed to prefer watching television and listening to music. However, Resident 76 was observed in bed with no sensory stimulation. These failures posed the risk for the residents to feel isolated. Findings: 1.a. On 12/8/22 at 0938 hours, an observation and interview was conducted with Resident 12. Resident 12 was observed in bed and awake. A television was observed hanging on the wall. The television was turned on but the display was blurred. The television was shared between Resident 12 and another resident. When asked what activities she did in the facility, Resident 12 stated she stayed in bed, watched television, and slept. Resident 12 stated she liked to watch television. Resident 12 acknowledged the television display was blurred. Resident 12 stated she wanted it to be clearer if possible. Resident 12 was observed attempted to reach the television remote control, but the television remote control cord was wrapped around the right side rail, and Resident 12 could not reach the television remote control. When asked how she felt about the blurred television display, Resident 12 stated I guess, all channels are like that. On 12/8/22 at 0940 hours, the ADON was asked to go into Resident 12's room to check the television display. The ADON did not enter the room but stated she did not know anything about television so she would call the maintenance. On 12/8/22 at 0950 hours, an observation of Resident 12 and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified Resident 12's television display was blurred. The Maintenance Supervisor also verified Resident 12's television remote control cord was wrapped around the right side rail. The Maintenance Supervisor unwrapped the television remote control cord from the side rail. Resident 12 was able to reach the television remote control and changed the channels. All channels were blurred. The Maintenance Supervisor attempted to fix the television display, but the channels were still blurred. The Maintenance Supervisor stated they would probably have to buy a new television for the resident. Medical record review for Resident 12 was initiated on 12/7/22. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Activities assessment dated [DATE], showed Resident 12's current activity preferences included watching television and talking/conversing. The assessment form also showed Resident 12's preferred activity setting was in her own room and in day/activity room. Review of Resident 12's Progress Notes, under Activity Note dated 10/25/22, showed for quarterly review, Resident 12 continued to be alert, verbally responsive and able to make needs known. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 11 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0679 12 was assisted to group activities as tolerated, otherwise, provided 1:1 room visits. Level of Harm - Minimal harm or potential for actual harm Review of Resident 12's plan of care showed a care plan problem revised 7/18/22, to address Resident 12's requiring assistance and encouragement in attending and/or participating with planned activities program and the resident preferred activities. The interventions included to invite and assist the resident to activities daily, room visits when not going to group activities to accommodate their needs, and to offer alternate choice of activities per the resident preferences within their level of activities. Residents Affected - Few Further review of Resident 12's plan of care showed a care plan problem dated 10/25/22, to address Resident 12's activity participation challenged by behavioral symptoms, and need for 1:1 activities. The goal was for Resident 12 to participate in 1:1 activity without disruptive behavior three times per week for 90 days. b. Review of Resident 12's Documentation Survey Report showed the following: - In October 2022, Resident 12 was provided 11 room visits, and no group activity; - In November 2022, Resident 12 was provided 9 room visits, and one group activity; and - In December 2022, Resident 12 was provided group activity, independent activity, and room visit on 12/9/22. On 12/9/22 at 1456 hours, an interview and concurrent medical record review for Resident 12 was conducted with the Activities Assistant. The Activities Assistant verified the above findings. When asked about Resident 12's activities, the Activities Assistant stated Resident 12 was non-verbal and did not go out of the room for activities. The Activities Assistant stated Resident 12 mostly stayed in bed and watched television. The Activities Assistant was informed Resident 12 could actually talk and was assessed with clear speech; and talking/conversing was one of her preferred activity preferences. The Activities Assistant stated when the residents could not participate in group activities, the activities personnel would do room visits daily. The Activities Assistant verified Resident 12 was not provided activities per her in-room visits and group activities as per the assessment and plan of care. On 12/14/22 at 1147 hours, Resident 12 was observed in bed and awake. A different television observed hanging on the wall, the TV was turned on and the display had a clear reception. When asked about the television, Resident 12 smiled and gave a thumbs up. 2. On 12/7/22 at 0942, 1036, and 1232 hours; and 12/8/22 at 0830, 0950, 1040, 1135, 1331 and 1347 hours, Resident 76 was observed in bed, awake, and staring at the wall. There was no television, radio, or any sensory stimulation observed. On 12/8/22 at 1347 hours, an observation and concurrent interview for Resident 76 was conducted with CNA 3. When asked about Resident 76's activities, CNA 3 stated Resident 76 mostly stayed in bed, and Resident 76 was always awake during the day. CNA 3 stated Resident 76 did not do anything while in bed. When asked about any sensory stimulation such as television or radio, CNA 3 verified the TV was off, and there was no radio inside the resident's room. CNA 3 stated she plugged the TV in, but she forgot to turn it on for Resident 76. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 12 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medical record review for Resident 76 was initiated on 12/7/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's Activity assessment dated [DATE], showed Resident 76's current activity preferences included music and watching television. The assessment form also showed Resident 76's preferred activity setting was in her own room. Review of Resident 76's plan of care showed a care plan problem revised date 11/16/22, to address Resident 76's activity participation challenged by impaired cognition, non-verbal, and need for 1:1 activities. The goal was for Resident 76 to respond by eye contact and follow simple tasks in 1:1 activity programs that would be provided three times per week for 90 days. Review of Resident 76's Documentation Survey Report showed the following: - In November 2022, Resident 76 was provided 10 room visits; and - In December 2022, Resident 76 was provided independent activities on 12/2 and 12/9/22, and room visits on 12/3 and 12/9/22. On 12/9/22 at 1448 hours, an interview and concurrent medical record review for Resident 76 was conducted with the Activities Assistant. The Activities Assistant verified the above findings. When asked about Resident 76's activities, the Activities Assistant stated Resident 76 was non-verbal; the resident's activities was mostly in her room, watching television and sensory stimulation. The Activities Assistant verified Resident 76 was not provided activities or her in-room visits as per the assessment and plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 13 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 25 sampled residents (Resident 85) received necessary care and services to help prevent the development or worsening of pressure ulcers. Over the course of four hours, Resident 85 was observed in the same position with pressure points directly on the mattress. Resident 85 was immobile, and had a history of pressure ulcers with interventions to reposition every two hours. This failure put Resident 85 at risk for the development or worsening of pressure ulcers. Residents Affected - Few Findings: Review of the facility's P&P titled Policy: Pressure Sore Management (undated) showed all available measures shall be taken to reduce skin breakdown and pressure sores. The resident is to be repositioned as scheduled. Medical record review for Resident 85 was initiated on 12/7/22. Resident 85 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 85's History and Physical examination dated 4/25/22, showed Resident 85 did not have the capacity to understand and make decisions due to vegetative state (absence of responsiveness and awareness due to overwhelming dysfunction of the the brain) and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). Review of Resident 85's MDS dated [DATE], showed Resident 85 was totally dependent on staff and required assistance from two people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Review of Resident 85's Order Summary Report showed the following treatment orders: - An order dated 12/7/22, for left lateral (side) leg redness, cleanse with normal saline, pat dry, apply zinc oxide ointment, and cover with dry dressing every day shift until 1/7/23. - An order dated 11/1/22, for left lateral malleolus (ankle) fragile skin, cleanse with normal saline, pat dry, sure prep, and cover with hydrocolloid dressing every Monday for skin maintenance management until 2/5/23. - An order dated 11/1/22, for right lateral malleolus fragile skin, cleanse with normal saline, pat dry, sure prep, and cover with hydrocolloid dressing every Monday for skin maintenance management until 2/5/23. - An order dated 12/7/22, for right heel redness, cleanse with normal saline, pat dry, apply foam dressing daily for 30 days until 1/6/23. Review of Resident 85's wound risk assessment dated [DATE], showed Resident 85 was at high risk for skin breakdown. Review of Resident 85's wound management care plans dated 4/23/22, showed Resident 85 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 14 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few readmitted to the facility with right and left buttock pressure ulcer DTI (deep tissue injury), and left and right heel pressure ulcer DTI. Review of Resident 85's skin progress reports, showed the left and right buttock was resolved on 5/4/22. Further review of Resident 85's skin progress reports, showed resident was noted with right heel redness measuring 3 cm by 2 cm on 12/7/22. On 12/8/22 at 1150 hours, Resident 85 was observed in bed, lying on his right side. Resident 85's right lateral heel was directly against the bed surface, with a pillow between his knees. Resident 85's left leg was on top of the pillow. On 12/8/22 at 1339, 1445, and 1533 hours, Resident 85 was again observed in the same position as above. On 12/8/22 at 1432 hours, an interview was conducted with the ADON. The ADON was asked about Resident 85's treatments. The ADON stated Resident 85 had treatments for left lateral leg and right heel redness, and also for right and left lateral malleolus fragile skin. When asked if Resident 85 was able to reposition himself, the ADON stated no. On 12/8/22 at 1336 hours, an interview was conducted with LVN 7. LVN 7 stated he was assigned to Resident 87 for the 0700 to 1500 hours shift on 12/8/22. When asked if LVN 7 turned or did any ADL care for Resident 87 today, he stated no. On 12/8/22 at 1537 hours, a follow-up interview and concurrent facility document review was conducted with the ADON. The ADON was asked who the assigned CNA was for Resident 85. The ADON checked the assignment sheet and stated Resident 85 was not included in the assignment that day for CNA coverage, therefore no CNA was assigned for the 0700 hours to 1500 shift. Review of the facility's Nursing Staffing Assignment and Sign-In Sheet dated 12/7/22, showed Resident 85 was not assigned a CNA for the 0700-1500 hours shift on 12/7/22. On 12/8/22 at 1544 hours, an observation and concurrent interview was conducted with LVN 7 and CNA 4 at Resident 85's bedside. Resident 85 was again observed lying in bed in the same position as the prior observations. LVN 7 and CNA 4 repositioned Resident 85 on to his back and removed the pillow between his legs. Resident 85 was observed to have deep indents on his left lateral calf where his skin had been against the sheet and mattress. Resident 85 was observed to have a hydrocolloid bandage on his right lateral malleolus and a bandage on his right heel. On 12/8/22 at 1603 hours, an interview was conducted with the DON. The DON was asked who was responsible for ensuring residents were repositioned as ordered. The DON stated the CNA, treatment nurses, and charge nurses were responsible for repositioning residents. The DON was asked to show documentation Resident 85 was repositioned on 12/8/22, from 1150 to 1530 hours. The DON was unable to provide such documentation. On 12/9/22 at 1304 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated she was the treatment nurse for Resident 85. LVN 4 stated Resident 85 was observed on 12/7/22, with a stage one pressure ulcer to the right heel. LVN 4 stated there was no wound consult for the wound due to it being stage one. LVN 4 stated Resident 85 was at high risk for wounds due to diagnoses of diabetes, obesity, lumbar stenosis (narrowing of the spinal canal in your lower back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 15 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that may cause pain or numbness in the legs), and protein calorie malnutrition. LVN 4 stated interventions included treatments as ordered and offloading with no pressure on the heels. On 12/13/22 at 1029 hours, a telephone interview was conducted with the Wound Care Physician. The Wound Care Physician stated he first assessed Resident 85 in 4/22 when he was admitted to the facility with bilateral DTI to both heels. The Wound Care Physician stated he assessed Resident 85 again on 12/12/22, for a wound to the right heel and reclassified the wound as an arterial ulcer ( develops as the result of damage to the arteries due to lack of blood flow to tissue). The Wound Care Physician stated Resident 85 was at higher risk for development of a pressure ulcer due to having an existing arterial ulcer, and being diagnosed with diabetes and peripheral arterial disease (narrowing or blockage of the vessels that carry blood from the heart to the legs). The Would Care Physician stated he recommended offloading of the heels (every two hours) and iodine (a medication used to treat both acute and chronic wounds). Event ID: Facility ID: 555035 If continuation sheet Page 16 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the splint and hand rolls for two of 25 final sampled residents (Residents 17 and 76) were applied per the physician's orders. * The facility failed to ensure the bilateral knee splints for Resident 76 were applied for three to six hours daily per the physician's order. * The facility failed to ensure the hand rolls for Resident 17 were applied for six hours daily per the physician's order. These failures had the potential for the residents' contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) and range of motion to worsen. Findings: 1. Medical record review for Resident 76 was initiated on 12/7/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's Order Summary Report showed a physician's order dated 12/5/22, for the RNA program to apply bilateral knee splints for three to six hours daily. Review of Resident 76's Documentation Survey Report v2, under RNA program for application of bilateral knee splints for three to six hours daily, showed 15 on 12/7, 12/8, 12/9, 12/11, and 12/12/22, and 5 on 12/10/22. On 12/8/22 at 0830, 0950, 1040, 1135, 1331, and 1347 hours, Resident 76 was observed in bed without the bilateral knee splints applied. On 12/8/22 at 1347 hours, an observation for Resident 76 and concurrent interview was conducted with CNA 3. CNA 3 verified the above findings. CNA 3 stated she did not see the splints were applied to Resident 76 today. When asked to show where the splints were, CNA 3 was observed taking the splints from the closet. CNA 3 stated the splints were in the same place inside the closet as yesterday. When asked if she can apply the splints to the residents or remove the splints from the resident, CNA 3 stated no because she did not receive any training to apply or remove the splints. On 12/9/22 at 1021 and 1237 hours, Resident 76 was observed in bed without the bilateral knee splints applied. On 12/9/22 at 1257 hours, an interview and concurrent medical record review for Resident 76 was conducted with RNA 1 and RNA 2. When asked about Resident 76's bilateral knee splints, RNA 1 and 2 stated they have not applied the knee splints today. RNA 1 and 2 stated they applied the knee splints yesterday around 1400 hours and left the knee splints for the CNA to remove after three to six hours. RNA 1 and 2 were informed Resident 76 was observed without any knee splints yesterday, and the CNA who worked verified there were no knee splints applied to Resident 76 yesterday, and that same CNA worked 16 hours yesterday. RNA 1 and 2 stated they actually applied the knee splints to Resident 76 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 17 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few around 0900 to 1000 hours, and removed the knee splints around 1130 hours. RNA 1 and 2 verified the application was approximately one to two and a half hours, less than three to six hours per physician's order. When asked to provide documentation of the application of the knee splints to Resident 76 for three to six hours, RNA 1 and 2 showed their RNA documentation in PCC. RNA 1 and 2 stated the 5 or 15 on the Documentation Survey Report only showed the amount of minutes they spent in the application of the knee splints. RNA 1 and 2 verified there was no documentation the knee splints for Resident 76 was applied for three to six hours, as per the physician's order. On 12/14/22 at 0923 hours, an interview and concurrent medical record review for Resident 76 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings. The Rehabilitation Director stated the RNAs were responsible to apply the splints to the residents. The Rehabilitation Director stated the CNAs could remove the splints and the CNAs were expected to know how to remove the splints because that was taught in school. When asked about the documentation of the splint application, the Rehabilitation Director stated the RNAs document in PCC under Tasks. The Rehabilitation Director was informed the documentation only showed the minutes the RNAs spent in applying the splints but not the actual time Resident 76 had the splints on, the Rehabilitation Director stated the RNAs should put the actual time to show how long Resident 76 tolerated the bilateral splints. 2. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 12/7/22, for RNA to apply hand rolls for both hands for six hours daily. Review of Resident 17's Documentation Survey Report v2, under RNA program for application of hand rolls for both hands for six hours daily, showed 15 on 12/7, 12/8, and 12/9/22, 5 on 12/10/22, and 7.5 on 12/11 and 12/12/22. On 12/7/22 at 0829, 0831, and 0847 hours, on 12/8/22 at 0829, and 0922, 0928, 1220, and 1332 hours, and on 12/9/22 at 0840, 1244, 1247, and 1337 hours, Resident 17 was observed in bed without the hand rolls to both hands. On 12/9/22 at 1247 hours, an observation and concurrent interview for Resident 17 was conducted with CNA 4. CNA 4 verified Resident 17 did not have any of the hand rolls to both hands. CNA 4 stated he was not aware Resident 17 should have the hand rolls. On 12/9/22 at 1337 hours, a follow-up interview was conducted with CNA 4. CNA 4 verified Resident 17 did not have any hand rolls to both hands. CNA 4 stated Resident 17 had no hand rolls throughout his shift, and no one has come in to apply any of the hand rolls to Resident 17. On 12/14/22 at 0933 hours, an interview and concurrent medical record review for Resident 17 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings. The Rehabilitation Director stated the RNAs were responsible to apply the hand rolls to Resident 17 because the RNAs also provide exercises and stretch the resident's hands as they apply the handrolls, and also for accountability. When asked about the documentation of the hand roll application, the Rehabilitation Director stated the RNAs document in PCC under the Tasks section, and the RNAs should put the actual time to show how long Resident 17 had the hand rolls to both hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 18 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 33) remained free from accident hazards. * The facility failed to implement the bilateral floor mats and maintain the resident's bed in the low position as per the physician's order and plan of care. This failure had the potential to place the resident at risk for serious injury. Findings: On 12/7/22 at 0804 hours, during the initial tour of the facility, Resident 33 was observed lying in bed, with the bed high and not in the low position. One floor mat was in place on the left side; no floor mat was observed in place on the right side. Medical record review for Resident 33 was initiated on 12/7/22. Resident 33 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Fall Risk assessment dated [DATE], showed the resident was at high risk for falls. Review of Resident 33's plan of care showed a care plan problem dated 12/22/21, addressing Resident 33's risk for falls/injury related to impaired cognition, poor safety awareness/judgement, seizure disorder, and use of the low air loss mattress. The interventions included to maintain the bed in the low position and to implement bilateral floor mats. Review of Resident 33's Order Summary Report showed a physician's order dated 2/11/22, to maintain the bed in the low position and to implement floor mats to minimize potential injury from spontaneous/involuntary movement from the bed to the floor. On 12/7/22 at 1430 hours, Resident 33 was observed lying in bed with the bed high and not in the low position. One floor mat was in place on the left side; no floor mat was observed in place on the right side. On 12/7/22 at 1433 hours, an observation of Resident 33 was conducted with LVN 4. LVN 4 verified Resident 33's bed was high and not in the low position and only one floor mat was in place. LVN 4 was able to lower the resident's bed further and into the lowest position. A subsequent interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified they did not implement bilateral floor mats and maintain the resident's bed in the low position as per the physician's order and the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 19 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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** 8. Medical record review for Resident 75 was initiated on 12/7/22. Resident 75 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Residents Affected - Some Review of Resident 75's Order Summary Report showed an order dated 11/20/22, for ventilator mode: SIMV, TV 450, RR 10, FIO2 5 lpm, PSV 10, and peep + 5. On 12/7/22 at 1027 hours, an observation and concurrent interview was conducted with RT 2 at Resident 75's bedside. RT 2 was asked to check Resident 75's ventilator settings and alarms. RT 2 verified Resident 75 was on the above ordered settings. When asked about the RR alarm, RT 2 stated Resident 75's RR was set to alarm at 100. RT 2 stated she did not know why it was set so high, and an alarm set that high meant the staff might not know if the resident's RR was at an unsafe range. RT 2 stated the normal alarm value for RR was 45. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to meet the needs of 10 of 25 final sampled residents (Residents 17, 39, 43, 48, 51, 62, 75, 76, 86, and 359 ) and five nonsampled residents (Residents 52, 81, 84, 360, and 409). * The facility failed to ensure qualified and trained staff responded to Resident 51's ventilator alarm. This failure had the potential to result in poor health outcomes for the resident. * The facility failed to ensure the mechanical ventilator low and high pressure alarms for Residents 39, 48, 52, 81, and 84 were set within safe parameters. This posed the risk for delayed care and interventions if the residents' ventilators did not alarm when they should have to alert the staff the residents were in distress or disconnected from their ventilators. * The facility failed to ensure Resident 409 had a manual resuscitation device (a hand-held device used to provide ventilation to residents who are not breathing or not breathing adequately) at the bedside. This posed the risk of delayed intervention in the event of an emergency. * The facility failed to ensure Resident 75's ventilator respiratory rate alarm was set within safe parameters. This failure put Resident 75 at risk for a delay in necessary care and services. * The facility failed to ensure Residents 17, 43, 62, 76, 359, and Resident 360's nasal cannulas (soft tubing used to deliver oxygen via the nostrils), nebulizer masks, nebulizer bags and tubing (a device which delivers medicated mist to a person via a mouth piece or a face mask) were changed every seven days in accordance with the physician's order and the facility's P&P. In addition, the facility failed to ensure the oxygen tubing and nebulizer masks were stored in a clean bag. These failures had the potential for increased risks of infection. * Resident 86's oxygen tubing and nebulizer mask were not labeled to show when it was changed. Resident 86's oxygen tubing and nebulizer mask were not storage in a bag when not in use. This failure had the potential for increased risk of infection. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 20 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Some Review of the facility's P&P titled Ventilator Alarm Settings revised 11/2007 showed to maintain the high pressure alarm setting at a maximum of 30 cm of water pressure above the resident's peak airway/inspiratory pressure (PIP); and to maintain the low pressure alarm setting within a range of 10 cm of water pressure below the resident's PIP. According to the Clinical Application of Mechanical Ventilation 2014, Fourth Edition, the low pressure alarm is triggered if the PIP is less than the alarm setting. Conditions that may trigger the low pressure alarm may include circuit disconnection, exhalation valve driveline disconnection, endotracheal tube cuff leak, and a loose circuit connection. The high pressure alarm should be set at 10 to 15 cm H2O above the observed PIP. This alarm is triggered when the PIP is equal to or higher than the high pressure limit. The patient must be evaluated to determine the cause of the airflow obstruction. Common causes that trigger the high pressure alarm include water in the ventilator circuit, kinking or biting of the endotracheal tube, secretions in the airway, bronchospasm, mucus plugs, tension pneumothorax, decreases in lung compliance, increases in airway resistance, and coughing. Review of the facility's P&P titled Manual Resuscitation Device (Ambu-Bag) (undated) showed a manual resuscitator device will be placed at the bedside of each patient and on the emergency cart. 1. On 12/7/22 at 0804 hours, Resident 51 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator. CNA 2 was at the bedside providing ADL care to Resident 51 with the privacy curtain drawn. Resident 51's ventilator started audibly alarming, and RT 1 responded to the ventilator alarm. However, RT 1 stood at the doorway and did not enter the resident's room to assess the resident nor check the ventilator or ventilator connection. RT 1, while standing at the doorway, asked CNA 2 if Resident 51 was disconnected from the ventilator and instructed CNA 2 to clear the alarm. On 12/7/22 at 0810 hours, an observation of Resident 51 was conducted with CNA 2 who was still at the resident's bedside. CNA 2 pointed to the exhalation line connected to the exhalation valve of the ventilator circuit and stated the exhalation line was disconnected. CNA 2 stated he reconnected the exhalation line to the exhalation valve. CNA 2 verified RT 1 did not enter the room to assess Resident 51 nor the ventilator or ventilator connection. On 12/7/22 at 0816 hours, an interview was conducted with RT 1. RT 1 verified she did not enter Resident 51's room to assess the resident when the resident's ventilator alarmed. When asked why the ventilator alarmed, RT 1 stated she did not know what triggered the ventilator to alarm, whether it was due to a disconnection, high or low pressure, or another ventilator alarm type. RT 1 verified she asked the CNA to clear the ventilator alarm even though it was not within the CNA's scope of practice to troubleshoot or make changes to the ventilator settings/alarms. Medical record review for Resident 51 was initiated on 12/7/22. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 51's plan of care showed a care plan problem dated 4/22/19, to address ventilator alarms. Flashing alerts and audible alarms may be a result of high or low pressure alarms and may be caused by the resident being turned; kinked tubing; the resident moving; coughing; increased pulmonary secretions the resident attempting to speak, bearing down, or straining; and a disconnected or leaking circuit/tubing. The goal was to provide monitoring and care for ventilator dependent residents to ensure their respiratory needs were met and to ensure respiratory distress was resolved or prevented. The interventions included for the staff to promptly enter the resident's room and assess (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 21 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 the resident when there is an audible ventilator alarm. Level of Harm - Minimal harm or potential for actual harm On 12/7/22 at 0926 hours, an interview was conducted with the Lead RT. The Lead RT verified it was not within the CNA's scope of practice to manipulate the ventilator settings or to silence ventilator alarms. The Lead RT verified the RTs should promptly enter the resident's room to assess the resident and the ventilator alarm when the ventilator alarmed. Residents Affected - Some 2. On 12/7/22 at 0845 hours, Resident 48 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 46; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 97. On 12/7/22 at 0906 hours, an interview was conducted with RT 2. RT 2 stated the low pressure alarm should be set 10 cm H2O below the resident's observed PIP and the high pressure alarm should be set up to 30 cm H2O above the resident's observed PIP. RT 2 stated the low pressure alarm was important because it alerted the staff if the resident was disconnected from the ventilator, and the high pressure alarm alerted the staff if the resident had an airway obstruction. RT 2 stated if the high pressure alarm was set too high it would take longer or take higher pressures for the ventilator to alarm and could potentially delay interventions. Following the interview, an observation of Resident 48's ventilator settings was conducted with RT 2. RT 2 stated she was not assigned to Resident 48 but would assist with checking the resident's ventilator settings. RT 2 verified how to check the ventilator settings. Resident 48's observed PIP on the ventilator was 32; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 97. RT 2 verified Resident 48's low and high pressure alarms were not set according to the facility's P&P. 3. On 12/7/22 at 0855 hours, Resident 84 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 39; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. On 12/7/22 at 0910 hours, a concurrent observation and interview of Resident 84's ventilator settings was conducted with RT 2. RT 2 verified the observed PIP on Resident 84's ventilator ranged from 35 to 45; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. RT 2 verified both the low and high pressure alarms were not set within a safe limit based on Resident 84's observed PIP. 4. On 12/7/22 at 0854 hours, Resident 81 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 20; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. On 12/7/22 at 0911 hours, a concurrent observation and interview of Resident 81's ventilator settings was conducted with RT 2. The observed PIP on Resident 81's ventilator was 21; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. RT 2 verified the high pressure alarm was set too high. 5. On 12/7/22 at 0839 hours, Resident 52 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 35; the low pressure alarm was observed set at 8 and the high pressure alarm was observed set at 99. On 12/7/22 at 0913 hours, a concurrent observation and interview of Resident 52's ventilator settings was conducted with RT 2. The observed PIP on Resident 52's ventilator was 36; the low pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 22 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Some alarm was observed set at 8 and the high pressure alarm was observed set at 99. RT 2 verified the findings and stated both the low and high pressure alarms were not set within a safe limit based on the resident's observed PIP. 6. On 12/7/22 at 0758 hours, Resident 39 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 32; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. On 12/7/22 at 0919 hours, a concurrent observation and interview of Resident 39's ventilator settings was conducted with RT 2. The observed PIP on Resident 39's ventilator was 37; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. RT 2 verified the findings and stated both the low and high pressure alarms were not set within a safe limit based on the resident's observed PIP. 7. On 12/7/22 at 0833 hours, Resident 409 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. A manual resuscitation device was not observed at Resident 409's bedside. On 12/7/22 at 0916 hours, RT 2 verified a manual resuscitation device was not available at Resident 409's bedside, but should be in case of an emergency and Resident 409 required manual resuscitation. On 12/7/22 at 0926 hours, an interview was conducted with the Lead RT regarding the above findings for Residents 48, 84, 81, 52, 39, and 409. The Lead RT stated all three of the RTs were assigned to these residents. The Lead RT verified the low pressure alarm should be set 10 cm H2O below the resident's observed PIP and the high pressure alarm should be set up to 30 cm H2O above the resident's observed PIP. The Lead RT verified a manual resuscitator device should be placed at the bedside of each resident in case of medical emergencies or ventilator failure. 9. Review of the facility's P&P titled Oxygen Administration (undated) showed the following: - The oxygen tubing should be changed weekly and as needed, including the mask, cannula, nebulizer equipment, etc. When not in use, the oxygen tubing should be stored in a clean bag for example, a Ziplock bag; - The date, time, and initials should be noted on oxygen equipment when it is initially used when changed; and - The oxygen tubing should be used in manner that prevents it from touching the floor. On 12/7/22 at 0942 hours, Resident 76 was observed in bed, receiving oxygen via nasal cannula. The oxygen nasal cannula was undated. A nebulizer mask dated 11/8/22 was observed on Resident 76's side table. There was no bag set-up for the oxygen and nebulizer mask. On 12/7/22 at 1232 hours, an observation and concurrent interview for Resident 76 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 acknowledged Resident 76 was on continuous oxygen. LVN 2 stated the oxygen nasal cannula, nebulizer mask and tubing were supposed to be changed every Sunday by the treatment nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 23 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Some Medical record review for Resident 76 was initiated on 12/7/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's Order Summary Report showed the following physician's orders dated 12/1/22: -To administer oxygen at two liters per minute continuously via nasal cannula. May titrate up to five liters per minute for oxygen saturation less than 94% every shift; -To change nasal cannula/ mask as needed when soiled; and -To change nasal cannula/ mask every night shift every Sunday. Further review of Resident 76's Order Summary Report showed the following physician's orders dated 10/31/22: - budosemide (corticosteroid, medication used to control and prevent symptoms of asthma ( inhalation suspension 0.5 mg/2 ml every 12 hours; and - ipratropium-albuterol (anticholinergic, a combination medication used to treat chronic obstructive pulmonary disease) solution 0.5-2.5 mg one vial inhale every four hours as needed. 10. On 12/7/22 at 0918 hours, Resident 359 was observed in bed. An oxygen concentrator was observed near the resident's bed, and the nasal cannula attached to the oxygen concentrator was undated. A nebulizer mask dated 11/22/22 was observed on Resident 359's side table. There was no bag set-up for the oxygen and nebulizer mask. On 12/7/22 at 0948 hours, an observation and concurrent interview for Resident 359 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 359 used oxygen and nebulizer in the past, and Resident 359 was sent out and was just recently readmitted . LVN 2 stated the nasal cannula tubing and nebulizer mask should have been discarded. LVN 2 stated the oxygen nasal cannula, nebulizer mask and tubing were supposed to be changed every Sunday by the treatment nurse when these are being used or ordered routinely. LVN 2 stated if the oxygen and nebulizer were ordered as needed, the nasal cannula and nebulizer mask should be dated when it was first used and just changed when soiled. Medical record review for Resident 359 was initiated on 12/7/22. Resident 359 was readmitted to the facility on [DATE]. Review of Resident 359's Physician's Order showed the following physician's orders dated 2/15/19: -To administer oxygen at two liters per minute via nasal cannula as needed. May titrate up to five liters per minute for oxygen saturation less than 92 %; -To change oxygen tubing weekly (Sundays) 11-7 shift and as needed; -To change nasal cannula/ mask every seven days and as needed when soiled. Further review of Resident 359's medical record showed the physician's orders dated 11/20/22 to discontinue the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 24 of 60 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 555035 B. Wing (X3) DATE SURVEY COMPLETED A. Building 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Oxygen at two liters per minute via nasal cannula as needed. May titrate up to five liters per minute for oxygen saturation less than 92%, and - ipratropium-albuterol solution 0.5 - 2.5 (3) mg/3ml, one vial inhale orally via nebulizer every six hours for congestion/ wheezing. Residents Affected - Some 11. On 12/7/22 at 0829 hours, Resident 17 was observed in bed, receiving oxygen via nasal cannula. The oxygen nasal cannula was undated. An undated nebulizer mask was observed on Resident 17's side table. The end of the nebulizer mask tubing was touching the floor. There was no bag set-up for the oxygen and nebulizer mask. On 12/7/22 at 0831 hours, an observation and concurrent interview for Resident 17 was conducted with the ADON. The ADON verified the above findings. The ADON stated the nasal cannula tubing and nebulizer mask should be changed weekly. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed the following physician's orders dated: -12/1/22, to administer oxygen at two liters per minute continuously via nasal cannula. May titrate up to five liters per minute for oxygen saturation less than 94% every shift; -12/1/22, to change nasal cannula/ mask as needed when soiled; -12/1/22, to change nasal cannula/ mask every night shift every Sunday; and -12/4/22, to administer ipratropium-albuterol solution 0.5-2.5 mg one vial inhale every four hours as needed. 12. On 12/7/22 at 1002 hours, an observation and interview was conducted with Resident 43. Resident 43 was observed in bed, and awake. A nebulizer mask dated 8/6/22 was observed on Resident 43's side table. There was no bag set-up for nebulizer mask. When asked about the nebulizer mask, Resident 43 stated he no longer used a nebulizer and he did not know when was the last time he used it. On 12/7/22 at 1226 hours, an observation and concurrent interview for Resident 43 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 43 used nebulizer previously but the order has been discontinued. LVN 2 stated the nebulizer mask should have been discarded. Medical record review for Resident 43 was initiated on 12/7/22. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's physician's orders showed the following physician's orders dated -8/2/22, to administer ipratropium-albuterol solution every four hours as needed; and -12/4/22, to discontinue ipratropium-albuterol solution every four hours as needed. Review of Resident 43's medical record did not show any active orders for nebulizer treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 25 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Some 13. On 12/7/22 at 0910 hours, Resident 360 was observed in bed, receiving oxygen via nasal cannula. The oxygen nasal cannula was undated. There was no bag set-up for the oxygen tubing. On 12/7/22 at 0913 hours, an observation and concurrent interview for Resident 360 was conducted with the IP. The IP verified the above findings. The IP stated the oxygen tubing should have been dated when it was initially used. The IP stated she was not sure how often should they change the nasal cannula tubing, but she told the nurses they have to change it if it was soiled. The IP stated the NOC shift charge nurse was responsible to change the tubing. On 12/9/22 at 0940 hours, an interview, medical record review and facility P&P review was conducted with the DON. When asked how often the staff should change the oxygen tubing, and nebulizer mask, the DON stated the nasal cannula tubing and nebulizer masks should be changed weekly on Sunday by the NOC shift charge nurse, and will be checked by the treatment nurses on Mondays. The DON stated if the NOC shift charge nurse was not able to change the nasal cannula tubing and nebulizer masks, then the treatment nurses should change them. The DON also stated the nasal cannula and nebulizer masks should be changed whether these were being used routinely or as needed. 14. Medical record review for Resident 62 was initiated on 12/7/22. Resident 62 was admitted to facility on 7/23/19 and was readmitted to the facility on [DATE]. Review of Resident 62's Order Summary Report showed a physician order dated 12/1/2022 to administered oxygen at two liters per minute continuously via nasal cannula, may titrate up to five liter per minute for oxygen saturation less than 94 percent and change nasal cannula/mask every night shift every Sunday and as needed when soiled. Review of Resident 62's Order Summary Report showed a physician order dated 1/13/22 to administer Ipratropium-Albuterol Solution (nebulizer medication) 0.5-2.5 three mg per three ml, one unit dose via mask every six hours and every three hours as needed for prevention of shortness of breath, wheezing and respiratory distress. Review of Resident 62's November and December 2022 MAR showed, Resident 62 received nebulizer treatments every six hours daily. Review of Resident 62's December 2022 MAR showed Resident 62 received oxygen continuously via nasal and the nasal cannula/mask was changed on 12/4/22. However, Resident 62 was not provided with a new storage bag. On 12/7/22 at 0827 and 1031 hours, a plastic bag was observed hanging on the oxygen concentrator dated 9/25/22. Resident 62's nebulizer mask was observed on top of the bedside table inside a hazy plastic bag dated 9/25/22. On 12/7/22 at 1049 hours, a concurrent observation and interview was conducted with LVN 8. When asked how often Resident 62's nebulizer mask, nebulizer bags and oxygen tubing were change, LVN 8 stated it should be changed once a week on Sundays and as need. LVN 8 verified Resident 62's oxygen tubing bag and nebulizer mask bags were dated 9/25/22. When LVN 8 was asked to check the date when Resident 62's nebulizer mask was changed, LVN 8 stated Resident 62's nebulizer mask was dated 9/25/22. LVN 8 stated Resident 62 uses the nebulizer mask daily for breathing treatments. LVN 8 acknowledged giving Resident 62's breathing treatments but did not check when nebulizer mask was changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 26 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Some On 12/9/22 at 1334 hours, an interview was conducted with LVN 3. When asked how often oxygen tubing, nebulizer mask and plastic bags were changed, LVN 3 stated it should be change and dated weekly on Sundays and prn when dirty to decrease the risk of infection. 15. Medical record review for Resident 86 was initiated on 12/7/22. Resident 86 was admitted to the facility on [DATE]. Review of Resident 86's Order Summary Report showed a physician's order dated 4/2/22 to administer oxygen at two liter per minute via nasal canula and to administer Ipratropium-Albuterol Solution 0.5-2.5 three mg per 3 ml, inhale orally every six hours for shortness of breath or wheezing. Review of Resident 86's December 2022 MAR showed Resident uses oxygen treatment continuously and nebulizer treatments every six hours daily. Review of Resident 86's care plan problem for oxygen use had an intervention to change oxygen tubing weekly or as needed. On 12/7/22 at 0813 hours, Resident 86 was observed asleep using oxygen via nasal canula, a nebulizer mask on top of a plastic drawer and oxygen tubing coiled around a wheelchair handle. The tubing had no visible dates. On 12/7/22 at 1024 hours, an interview with Resident 86 was conducted. Resident 86 stated he uses oxygen all the time. When Resident 86 was asked about his oxygen tubing, Resident 86 stated he had it for more than a week. Resident 86 stated he used the oxygen tubing on the wheelchair when he went out of the room on 12/6/22. On 12/7/22 at 1059 hours, a concurrent observation and interview was conducted with LVN 8. When asked how often oxygen tubing, nebulizer masks and bags were changed, LVN 8 stated it should be changed every week on Sundays and as needed. LVN 8 verified Resident 86's oxygen tubing and nebulizer mask were not dated. LVN 8 verified Resident 86 was not provided with bags to store when the nebulizer mask and oxygen tubing were not in use. On 12/9/22 at 1334 hours, an interview was conducted with LVN 3. When asked how often oxygen tubing, nebulizer mask and plastic bag were changed, LVN 3 stated it should be change and dated weekly on Sundays and as needed when dirty to decrease the risk of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 27 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0698 Provide safe, appropriate dialysis care/services 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 observation, interview, and medical record review, the facility failed to ensure the medications were administered as ordered on dialysis (a treatment to rid the body of wastes and toxins when the kidneys fail to function) days for one of 25 final sampled residents (Resident 358). This had the potential for Resident 358 not being provided appropriate care and treatment, and the possibility of medical complications. Residents Affected - Few Findings: On 12/7/22 at 1049 hours, a concurent observation and interview was conducted with Resident 358. Resident 358 was observed in bed and awake. Resident 358 stated he went to dialysis on Mondays, Wednesdays, and Fridays. Resident 358 stated he usually left the facility for dialysis around 0500 hours and came back at 1000 hours or after. Resident 358 stated he was concerned he was missing his medications for 0600, 0700, 0800, and 0900 hours when he was at the dialysis. Medical record review for Resident 358 was initiated on 12/7/22. Resident 358 was readmitted to the facility on [DATE]. Review of Resident 358's Order Summary Report showed the following physician's orders dated: - 11/29/22, Resident 358 had dialysis treatments scheduled at an outside dialysis center every Monday, Wednesday, and Friday; - 11/16/22, to administer aspirin (a nonsteroidal anti-inflammatory drug) EC 81 mg tablet one time a day; - 11/17/22, to administer cranberry oral capsule (supplement) 425 mg three times a day; - 11/16/22, to administer docusate sodium (stool softener) 100 mg one capsule two times a day - 11/17/22, to administer docusate sodium 100 mg capsule one time day; - 11/16/22, to administer famotidine (medication used to treat stomach or intestinal ulcers) 20 mg one time a day; - 11/16/22, to administer Florastor (probiotic medication) 250 mg one capsule two times a day; - 11/16/22, to administer folic acid (vitamin supplement) 1 mg one tablet by mouth one time a day; - 11/16/22, to administer gabapentin (medication used to treat nerve pain) 100 mg one capsule by mouth every eight hours; - 11/16/22, to administer regular insulin (medication used to treat diabetes) per sliding scale before meals; - 11/17/22, to administer multivitamin with mineral (supplement) one tablet by mouth one time a day; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 28 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0698 - 11/16/22, to administer pro-stat (supplement) 30 ml three times a day; Level of Harm - Minimal harm or potential for actual harm -11/16/22, to administer Rena Vite (supplement) one tablet one time a day; - 11/29/22, to administer Renvela (medication used to control phosphorus levels) 800 mg one time a day; Residents Affected - Few - 11/16/22, to administer Symbicort (medication used long-term to improve symptoms of chronic obstructive pulmonary disease) 160-4.5 mcg two puffs orally every 12 hours; - 11/16/22, to administer vitamin C (supplement) 500 mg one tablet one time a day; - 11/17/22, to administer vitamin D3 (supplement) 25 mcg one tablet one time day; and - 11/17/22, to administer zinc sulfate (supplement) 200 mg one capsule one time a day. Review of Resident 358's MAR for November 2022 showed Resident 358 was not administered the following medications: - aspirin, folic acid, multivitamin with mineral, vitamin D3, zinc, docusate sodium, Florastor, cranberry, and pro-stat, on 11/23, 11/28, and 11/30/22 at 0900 hours; - famotidine 20 mg on 11/18 and 11/28/22 at 0600 hours; - vitamin C on 11/21, 11/23, and 11/30/22 at 0900 hours; - Symbicort, Rena Vite, on 11/23, and 11/30/22 at 0900 hours; - gabapentin on 11/28/22 at 0600 hours; -insulin on 11/21, and 11/28/22 at 0630 hours; and - calcium on 11/21, 11/23, and 11/28/22 at 0715 hours. The MAR showed Resident 358 had an order dated 11/16/22, for calcium acetate (supplement) 667 mg by mouth with meals. The record showed this order was discontinued on 11/29/22. Review of Resident 358's MAR for December 2022 showed Resident 358 was not administered the following medications: - aspirin, docusate sodium, folic acid, multivitamin with minerals, Florastor, Symbicort, cranberry, pro-stat, and Renvela, on 12/5, and 12/7/22 at 0900 hours; and - famotidine on 12/8/22 at 0600 hours. Review of Resident 358's medical record failed to show the facility informed the dialysis center regarding any held medications, or obtained a physician's order to hold the medications during dialysis. On 12/9/22 at 1333 hours, an interview and concurrent medical record review for Resident 358 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 29 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0698 Level of Harm - Minimal harm or potential for actual harm conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 358 usually left the facility at 0530 hours and returned at 1100 hours. LVN 2 stated when Resident 358 arrived at 1000 hours, he was able to give the medications due at 0900 hours because he had the one-hour window. LVN 2 stated when Resident 358 returned after the one hour window then he would hold the medications and documented in the MAR. LVN 2 verified there was no physician orders for the medications to be held prior to dialysis. Residents Affected - Few On 12/9/22 at 1346 hours, an interview and concurrent medical record review for Resident 358 was conducted with RN 2. RN 2 verified the above findings. RN 2 verified there was no physician's orders for the medications to be held during dialysis. On 12/9/22 at 1410 hours, an interview and concurrent medical record review for Resident 358 was conducted with the DON. The DON verified the above findings. The DON stated they would clarify with the physician regarding holding the medications during dialysis, or to change the medication administration times to when Resident 358 comes back from dialysis. Cross reference to F760. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 30 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **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 three of 25 residents (Residents 26, 57, and 48 ) were properly assessed for the use of side rails prior to the initiation of bilateral side rails. * The facility failed to assess Resident 26 for the use of bilateral side rails prior to use. * The facility assessed Resident 57 as not being indicated for the use of side rails, however bilateral side rails were in use. * The facility failed to obtain a physician's order, review the risks and benefits of the side rails with Resident 48 and/or resident representative, and failed to obtain informed consent for the use of the side rails. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: Review of the facility's P&P titled Policy: Side rail use when not a restraint (undated) showed when using the side rails not as a restraint, first complete physical restraint assessment form. If the physical restraint assessment form demonstrates that the resident is immobile and cannot voluntarily get out of bed due to a physical limitation, then proceed with the accompanying IDT for use of both side rails not as a restraint. The licensed nurse should obtain an order from the attending physician for the use of side rails. The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, or acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. 1. On 12/7/22 at 1027 hours, during the initial tour of the facility, Resident 26 was observed in bed with bilateral side rails elevated. Subsequent observations showed Resident 26 in bed with bilateral side rails elevated. For example: - On 12/8/22 at 1153 hours. - On 12/8/22 at 1344 hours. Medical record review for Resident 26 was initiated on 12/7/22. Resident 26 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed an order dated 7/31/18, for bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated HOB for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 31 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0700 management and provision of enteral feeding. Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's medical record failed to show an assessment for the use of bilateral side rails. Residents Affected - Few On 12/14/22 at 1103 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 26's bedside. LVN 5 verified Resident 26 was in bed with bilateral 1/4 side rails elevated. On 12/14/22 at 1104 hours, an interview and concurrent medical record review for Resident 26 was conducted with RN 1. RN 1 was asked to show Resident 26's assessment for the use of side rails. RN 1 reviewed the record and was unable to find an assessment. Cross reference F656, example #2. 2. On 12/7/22 at 1030 hours, during an initial tour of the facility, Resident 57 was observed in bed with bilateral 1/2 side rails elevated. Subsequent observations showed Resident 57 in bed with bilateral 1/2 side rails elevated on multiple occasions. For example: - On 12/8/22 at 1156 hours. - On 12/9/22 at 0851 hours. - On 12/14/22 at 1021 hours. Medical record review for Resident 57 was initiated on 12/7/22. Resident 57 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of the side rail safety/entrapment assessment dated [DATE], failed to show whether side rail use was indicated for Resident 57. The section under recommendations was left blank. Review of the Side rail safety/entrapment assessment dated [DATE], showed side rail is not indicated at this time. On 12/14/22 at 1028 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 57's bedside. LVN 5 verified Resident 57 was in bed with bilateral 1/2 side rails elevated. When asked who was responsible for assessing residents for side rail use, LVN 5 stated any admitting nurse could assess for the use of side rails. On 12/14/22 at 1029 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated residents were assessed upon admission for the use of side rails. RN 1 was asked to show Resident 57's assessment for the use of side rails. RN 1 stated the most recent side rail safety/entrapment assessment for Resident 57 was completed 10/9/21, and showed side rail use was not indicated at this time. Upon further review, the assessment showed side rail use is indicated was now selected. RN 1 stated she changed the recommendations to side rail use indicated as we were conducting the interview. 3. Review of the facility's P&P titled Side Rail Use When Not a Restraint (undated) showed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 32 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0700 Level of Harm - Minimal harm or potential for actual harm licensed nurse should obtain an order from the attending physician to include the resident may have both side rails up when in bed. On 12/7/22 at 0845 and 1127 hours, and on 12/13/22 at 0831 and 0939 hours, Resident 48 was observed lying in bed with bilateral side rails elevated by the head of the bed. Residents Affected - Few Medical record review for Resident 48 was initiated on 12/7/22. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 48's History and Physical examination dated 11/22/22, showed Resident 48 had diagnoses including spastic recurrent seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Review of Resident 48's Side Rail Safety/Entrapment assessment dated [DATE], showed side rails were not indicated for Resident 48. Review of Resident 48's Order Summary Report dated 12/13/22, failed to show a physician's order for the use of side rails. Medical record review for Resident 48 did not show informed consent was obtained for the use of the bilateral side rails. On 12/13/22 at 0949 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above information. RN 1 verified Resident 48's Side Rail Safety/Entrapment assessment dated [DATE], showed side rails were not indicated for Resident 48. RN 1 verified there was no physician's order for the use of side rails and verified informed consent was not obtained prior to the use of the bilateral side rails. Cross reference to F656, example #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 33 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure a medication that was stored beyond pharmacy recommendations was not administered for one of 32 nonsampled residents (Resident 4). * Resident 4 was administered Latanoprost (an eyedrop medication) that was opened on 10/15/22, and stored beyond 28 days. This failure had a potential to place the resident at risk for adverse effects. Findings: According to the facility P&P titled Medication Storage in the Facility dated April 2008, medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of accordingly to procedures of medication disposal, and reordered from pharmacy if a current order exists. Review of the Lexicomp (clinical drug resource) guide updated 12/13/22, showed store Latanoprost solution intact bottles under refrigeration at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit). Protect from light. May be maintained at temperatures up to 40 degrees Celsius (104 degrees Fahrenheit) for up to eight days during shipment. Once opened, the container may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks. Medical record review for Resident 4 was initiated on 12/13/22. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/1/11 to administer Latanoprost Solution 0.005 percent, instill one drop in both eyes at bedtime. On 12/9/22 at 1450 hours, a concurrent observation, interview, and medical record review was conducted with LVN 8. Resident 4's Latanoprost medication dated 10/15/22, was found in Medication Cart 2. Resident 4's Latanoprost medication was labeled: once bottle opened, discard unused medication after 28 days. LVN 8 verified Resident 4's Latanoprost medication was opened on 10/15/22 and acknowledged it was passed 28 days. Review of Resident 4's December 2022 MAR was conducted with LVN 8. LVN 8 verified Resident 4 received Latanoprost medication daily at bedtime. Review of Resident 4's Pharmacy Supplies Record conducted on 12/14/22 showed, Resident 4's Latanoprost medication was dispensed on 10/6 and 12/10/22. On 12/14/22 at 0933 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON was made aware of Resident 4's Latanoprost medication opened 10/15/22, was found inside Medication Cart 2 and labeled to be discarded 28 days once opened. Review of Resident 4's November and December 2022 MAR showed, Resident 4 had been receiving the Latanoprost medication daily at bedtime. The ADON was unable to provide information on Resident 4's Latanoprost medication refill in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 34 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 November 2022. The ADON acknowledged Resident 4 received an old Latanoprost eyedrops medication that could invite growth of mold and bacteria. Cross reference to F761, example #3. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 35 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/9/22 at 1348 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1 at Medication Cart 1. LVN 1 was asked to select a random PRN controlled medication from the cart. LVN 1 showed a bubble pack dated 8/16/22, for Resident 89 for lorazepam one mg tablet to administer one tablet by mouth every eight hours as needed for anxiety with no stop date. LVN 1 was unable to show any documentation as to why the order had no stop date. Medical record review for Resident 89 was initiated on 12/9/22. Resident 89 was admitted to the facility on [DATE]. Review of Resident 89's History and Physical examination dated 5/9/22, showed Resident 89 did not have the capacity to understand and make decisions and listed a surrogate decisionmaker. Review of Resident 89's Order Summary Report showed an order dated 8/16/22, for Ativan (lorazepam) oral tablet one mg to administer one tablet by mouth every eight hours as needed for anxiety manifested by restlessness and agitation. There was no stop date documented. Review of Resident 89's MAR showed Resident 89 received three doses of Ativan in 8/22, 14 doses in 9/22, 11 doses in 10/22, four doses in 11/22, and two doses in 12/22. Cross reference to F552. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 25 final sampled residents (Residents 17, 43, and 89) were free from the unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure Resident 17 was monitored for the behavior and side effects related to the use of Remeron (medication used to treat depression), and venlafaxine (medication used to treat depression) and clozapine (medication used to treat schizophrenia). In addition, the monthly behavior summary was not completed for Abilify (medication used to treat schizophrenia), clozapine, and venlafaxine. * The facility failed to ensure Resident 43 was monitored for the side effects of trazodone (medication used to treat depression). * The facility failed to ensure the physician's order for PRN lorazepam for Resident 89 was limited to a 14 days duration. These failures had the potential for Residents 17, 43, and 89 to have adverse complications from the medications. Findings: 1. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 36 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Review of Resident 17's Order Summary Report showed the following physician's orders dated: Level of Harm - Minimal harm or potential for actual harm - 10/30/22, to administer Abilify 10 mg one tablet one time a day for schizophrenia manifested by episodes of angry outburst causing harm to self or others; Residents Affected - Few - 10/27/22, to administer Abilify 15 mg one tablet one time a day for schizophrenia manifested by episodes of angry outburst causing harm to self or others; - 10/30/22, to administer clozapine 100 mg one tablet two times a day for schizophrenia manifested by episodes of angry outburst causing harm to self or others; - 12/8/22, to administer Remeron 15 mg at bedtime for appetite stimulant; - 10/27/22, to administer risperidone (medication used to treat schizophrenia) 3 mg two times a day for schizophrenia manifested by irritable mood causing stress; - 10/27/22, to administer venlafaxine 75 mg one time a day for depression manifested by verbalization of feelings of hopelessness/ helplessness affecting daily living activities; - 10/27/22, to monitor for potential side effects for antipsychotic medications (clozapine, Aripiprazole, risperidone) every shift; - 10/27/22, to monitor episodes of schizophrenia manifested by episodes of angry outburst causing harm to self or others for Abilify use, every shift; - 10/27/22, to monitor episodes of schizophrenia manifested by episodes of angry outburst causing harm to self or others for risperidone use, every shift; and - 10/27/22, to monitor episodes of schizophrenia manifested by visual hallucinations causing fear for clozapine use, every shift. Review of Resident 17's MAR for November 2022 showed the following: - Resident 17 was administered Abilify, venlafaxine, clozapine and risperidone from 11/1 to 11/30/22; - Resident 17 was monitored for the side effects of antipsychotic medications (clozapine, Aripiprazole, risperidone) from 11/1 to 11/30/22, every shift; and - Resident 17 was monitored for the behavior related to the use of risperidone and Abilify from 11/1 to 11/30/22. However, there was no monitoring for the behavior and side effects related to the use of Remeron and venlafaxine. In addition, the behavior monitoring was not correct in relation to the use of clozapine. Review of Resident 17's MAR for December 2022 showed the following: - Resident 17 was administered Abilify, clozapine, risperidone and venlafaxine from 12/1 to 12/9/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 37 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 - Resident 17 was administered Remeron from 12/1 to 12/8/22 Level of Harm - Minimal harm or potential for actual harm -Resident 17 was monitored for the side effects of antipsychotic medications (clozapine, Aripiprazole, risperidone) 12/1 to 12/9/22 every shift; and Residents Affected - Few - Resident 17 was monitored for the behavior related to the use of risperidone and abilify from 12/1 to 12/9/22, every shift. a. However, there was no monitoring for the behavior and side effects related to the use of Remeron and venlafaxine. b. In addition, the behavior monitoring was not correct in relation to the use of clozapine. c. Review of Resident 17's Psychotropic Summary Sheets for clozapine, Abilify, risperidone, and venlafaxine were left blank. Further review of Resident 17's medical record did not show the behavior and side effects related to the use of Remeron and venlafaxine were monitored, and there was no documentation to show the behavior related to the use of clozapine was monitored. In addition, the monthly behavior summary sheets related to the use of Abilify, risperidone, and venlafaxine were not completed. On 12/13/22 at 1034 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 could not locate any documentation to show the side effects related to the use of venlafaxine was monitored, and the behavior related to the use of clozapine was monitored. On 12/13/22 at 1100 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 6. LVN 6 verified the above findings. LVN 6 verified the monthly behavior summary sheets related to the use of Abilify, risperidone, and venlafaxine were not completed. LVN 6 stated the NOC shift nurses were supposed to complete the monthly behavior summary sheets at the end of each month. 2. Medical record review for Resident 43 was initiated on 12/7/22. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Order Summary Report showed the following physician's orders dated: - 8/3/22, to administer fluoxetine (medication used to treat depression) 40 mg one capsule by mouth one time a day for depression manifested by verbalization of extreme sadness/ causing social withdrawal affecting daily living activities; - 8/3/22, to administer trazodone 100 mg one tablet by mouth at bedtime for depression manifested by inability to sleep; - 8/3/22, to monitor potential side effects of antidepressant fluoxetine, every shift; - 8/3/22, to monitor episodes of depression manifested by verbalization of extreme sadness causing social withdrawal affecting daily living activities for fluoxetine use, every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 38 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 - 8/3/22, to monitor episodes of depression manifested inability to sleep. Monitor hours of sleep; and Level of Harm - Minimal harm or potential for actual harm - 8/3/22, to monitor episodes of insomnia manifested by inability to sleep/ sleeplessness. Monitor hours of sleep Residents Affected - Few Review of Resident 43's MAR for October 2022 showed the following: - Resident 43 was administered fluoxetine and trazodone from 10/1 to 10/31/22; - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 10/1 to 10/31/22; and - Resident was monitored for the behavior related to the use of trazodone from 10/1 to 10/31/22. Review of Resident 43's MAR for November 2022 showed the following: - Resident 43 was administered fluoxetine and trazodone from 11/1 to 11/30/22 - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 11/1 to 11/30/22 and - Resident was monitored for the behavior related to the use of trazodone from 11/1 to 11/30/22. Review of Resident 43's MAR for November 2022 showed the following: - Resident 43 was administered fluoxetine and trazodone from 11/1 to 11/30/22 - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 11/1 to 11/30/22 and - Resident 43 was monitored for the behavior related to the use of trazodone from 11/1 to 11/30/22. Review of Resident 43's MAR for December 2022 showed the following: - Resident 43 was administered fluoxetine from 12/1 to 12/8/22; - Resident 43 was administered trazodone from 12/1 to 12/7/22; - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 12/1 to 12/8/22; and - Resident 43 was monitored for the behavior related to the use of trazodone from 12/1 to 12/8/22. Further review of Resident 43's medical record did not show the side effects related to the use of trazodone was monitored. On 12/13/22 at 1057 hours, an interview and concurrent medical record review for Resident 43 was conducted with the ADON. The ADON verified the above findings. The ADON could not locate any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 39 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 documentation the side effects related to the use of trazodone was monitored. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 40 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.25%. Two of four licensed nurses (LVNs 1 and 7) who were observed during the medication administration were found to have made errors, when LVNs 1 and 7 failed to administer a prescribed medication to their residents. These failures had the potential to negatively affect the residents' health. Residents Affected - Few Findings: 1. On 12/8/22 at 0818 hours, a medication administration observation for Resident 95 was conducted with LVN 1. LVN 1 stated Resident 95 was administered medications via the GT. LVN 1 prepared and administered the following medications to Resident 95: -one tablet of docusate sodium (stool softener) 100 mg, -7.5 ml of ferrous sulfate (iron supplement) 220 mg/5 ml, -one tablet of multivitamin with mineral, -5 ml of Vitamin C 500 mg/5 ml, and - one tablet of Vitamin D3 25 mcg. However, review of Resident 95's Order Summary Report showed a physician's order dated 10/8/22, to administer 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) three times a day at 0900, 1300, and 1700 hours for UTI (urinary tract infection, an infection that happen when bacteria enter the urethra and infect the urinary tract) prophylaxis. On 12/8/22 at 1018 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified UTI-Stat was not administered to Resident 95 because the medication was not available. Cross reference to F842, example 1. 2. On 12/8/22 at 0857 hours, a medication administration observation for Resident 38 was conducted with LVN 7. LVN 7 stated Resident 38 was administered medications via the GT. LVN 7 prepared and administered the following medications to Resident 38: -one tablet of Apitom (medication used to treat seizure disorder) 800 mg, -one tablet of carvedilol (medication used to treat high blood pressure) 3.125 mg, -five tablets of Vitamin D3 1,000 unit, -two tablets of docusate sodium (stool softener) 100 mg, -7.5 ml of ferrous sulfate (iron supplement) 220 mg/5 ml, -12 ml of levetiracetam solution (medication used to treat seizure disorder) 100 mg/ml, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 41 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0759 - one tablet of multivitamin with mineral, and Level of Harm - Minimal harm or potential for actual harm -5 ml of Vitamin C 500 mg/5 ml. Residents Affected - Few However, review of Resident 38's Order Summary Report showed a physician's order dated 11/24/21, to administer 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) two times a day at 0900 and 1700 hours for UTI prophylaxis. On 12/8/22 at 1022 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings. LVN 7 verified UTI-Stat was not administered to Resident 38 because the medication was not available. Cross reference to F842, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 42 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 358) was free from significant medication errors. The facility failed to administer Resident 358's heparin (medication used to prevent blood clot) during dialysis days and failed to ensure a physician's order was obtained to hold the heparin medication as ordered on dialysis days. This failure placed Resident 358 at risk for medical complications. Residents Affected - Few Findings: On 12/7/22 at 1049 hours, Resident 358 was observed in bed, awake. Resident 358 stated he went to dialysis on Mondays, Wednesdays, and Fridays. Resident 358 stated he usually left the facility for dialysis around 0500 hours and came back at 1000 hours or after. Resident 358 stated he was concerned he was missing his medications for 0600, 0700, 0800, and 0900 hours when he was at the dialysis. Medical record review for Resident 358 was initiated on 12/7/22. Resident 358 was readmitted to the facility on [DATE]. Review of Resident 358's Order Summary Report showed the following physician's orders dated: -11/29/22, Resident 358 had dialysis treatments scheduled at an outside dialysis center, every Monday, Wednesday, and Friday; and -11/16/22, to administer heparin injection 5000 unit/ml subcutaneously (under the skin) every 12 hours. Review of Resident 358's MAR for November 2022 showed Resident 358 was not administered heparin on 11/23, 11/28, and 11/30/22 at 0900 hours; Review of Resident 358's MAR for December 2022 showed Resident 358 was not administered heparin on 12/5 and 12/7/22 at 0900 hours. Review of Resident 358's medical record failed to show the facility informed the dialysis center regarding any held medications or obtained a physician's order to hold the medications during dialysis. On 12/9/22 at 1333 hours, an interview and concurrent medical record review for Resident 358 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 verified there was no physician's orders for the medications to be held prior to dialysis days. On 12/9/22 at 1346 hours, an interview and concurrent medical record review for Resident 358 was conducted with RN 2. RN 2 verified the above findings. RN 2 verified there was no physician's orders for the medications to be held during dialysis days. On 12/9/22 at 1410 hours, an interview and concurrent medical record review for Resident 358 was conducted with the DON. The DON verified the above findings. The DON stated they would clarify with the physician regarding holding the medications during the dialysis, or to change the medication administration times to when Resident 358 comes back from dialysis days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 43 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0760 Cross reference to F698. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 44 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to store the medications and supplies safely according to the manufacturer or pharmacy recommendations. * Medication Cart 2 had two expired boxes of blood glucose strips (small, plastic strips that help to test and measure blood sugar levels). This had the potential for use of expired supplies. * Medication Cart 2 had Resident 4's bottle of Latanoprost (eyedrops medication) opened on [DATE] and labeled once opened, discard unused medication after 28 days. This failure had the potential for the administration of deteriorated medication. * Resident 459's discontinued Gabapentin (medication used to treat nerve pain) tablets were found in Medication Cart 2. This failure had the potential to negatively impact the resident's well-being. Findings: According to the facility P&P titled Medication Storage in the Facility dated [DATE], the medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of accordingly to procedures of medication disposal, and reordered from pharmacy if a current order exists. 1. On [DATE] at 1450 hours, a concurrent observation and interview was conducted with LVN 8 of Medication Cart 2. There were two unopened boxes of blood glucose test strips with expiration date of [DATE], in the left third drawer. LVN 8 verified the expired strips should not be in the cart and should have been discarded. On [DATE] at 0933 hours, an interview was conducted with the ADON. When ask regarding the expired supplies or medications inside medication cart, the ADON stated any expired supply or medication should be removed out of the medication cart right away and be placed in the medication room for disposal. 2. Review of the Lexicomp (clinical drug resource) guide updated [DATE], showed to store Latanoprost solution intact bottles under refrigeration at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit). Protect from light. May be maintained at temperatures up to 40 degrees Celsius (104 degrees Fahrenheit) for up to eight days during shipment. Once opened, the container may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for six weeks. Medical record review for Resident 4 was initiated on [DATE]. Resident 4 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated [DATE] to administer Latanoprost Solution 0.005 percent, instill one drop in both eyes at bedtime. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 45 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 On [DATE] at 1450 hours, a concurrent observation and interview was conducted with LVN 8 of Medication Cart 2. Resident 4's Latanoprost medication was observed in a container dated [DATE] and labeled: once bottle opened, discard unused medication after 28 days. LVN 8 verified that Resident 4's Latanoprost medication was opened on [DATE], and acknowledged Resident 4's Latanoprost had passed 28 days and should have been discarded. Residents Affected - Few On [DATE] at 0933 hours, an interview was conducted with the ADON. When ask on how to discard the Latanoprost medication, the ADON stated to follow pharmacy labeling on when to discard the medication. The ADON stated if pharmacy label indicated to discard after 28 days once opened, it should have been taken out of the medication cart right away. 3. Review of Resident 459's medical record was initiated on [DATE]. Resident 459 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 459's Order Summary Report showed a physician order dated [DATE] to administer gabapentin 300 mg two capsules by mouth in the afternoon and one capsule by mouth as needed for neuropathy (nerve pain). On [DATE] at 1450 hours, inspection of Medication Cart 2 was conducted with LVN 8. Resident 459's gabapentin 600 mg tablets medication pack was observed in the left bottom drawer. When asked about Resident 459's Gabapentin tablets, LVN 8 stated Resident 459's gabapentin tablets had been discontinued and the order was changed. LVN 8 further stated Resident 459's discontinued gabapentin tablets should have been taken out of the cart and brought to medication room for disposal. On [DATE] at 0933 hours, a concurrent interview and medical record review was conducted with the ADON. When asked regarding Resident 459's gabapentin medication, the ADON stated Resident 459's gabapentin 600 mg tablet were changed to gabapentin 300 mg capsule on [DATE]. The ADON further stated when a resident's medication was changed, the old medication had to be taken out of the medication cart right away to prevent accident of giving the wrong dose. Cross reference to F755. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 46 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility document review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aide 1 was unable to correctly test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces. This unsafe food practice had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food from the kitchen. Findings: Review of the Form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 12/7/22, showed 57 of the 104 residents residing in the facility received foods prepared in the kitchen. According to the USDA Food Code 2017, 4-301.12, Manual Ware washing, sink compartment requirements, alternative manual ware washing equipment must provide accomplishment of the application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals and sanitation. Review of the manufacturer's guidelines for the quaternary ammonium sanitizer test strips showed the testing instructions, to tear off a strip of test paper and dip it into room temperature sanitizing solution for ten seconds. On 12/9/22 at 0840 hours, an observation and interview was conducted with Dietary Aide 1. Dietary Aide 1 was asked to demonstrate how to check the sanitizing solution. Dietary Aide 1 was observed wearing gloves, and observed changing the sanitizing solution in the bucket. Dietary Aide 1 was observed tearing off a testing strip from the container with wet gloves on. Dietary Aide 1 was observed dipping the strip into a red bucket filled with sanitizer. When asked what the appropriate range was for the sanitizing solution, Dietary Aide 1 did not answer. When asked how long should the strips be in the solution, Dietary Aide answered five seconds. On 12/9/22 at 0858 hours, an interview was conducted with the DSS. When asked how competencies were evaluated, the DSS stated the staff have monthly in-services. The DSS was informed Dietary Aide 1 was not able to correctly demonstrate how to check the chemical concentration of the sanitizing solution. The DSS stated she would have to do an inservice immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 47 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure the proper hand hygiene was used in between glove changes and when handling dirty to clean dishes. * The facility failed to ensure the proper labeling and dating of foods in the kitchen. * The facility failed to air dry the equipment. * The facility failed to ensure the plates were free from chip and cracks. * The facility failed to ensure the chlorine strips and pH sanitizer strips had not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 Resident Census and Conditions of Residents completed by the facility and dated 12/7/22, showed 57 of the 104 residents residing in the facility received foods prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 2-301, When to Wash, the food employees shall clean their hands before donning gloves to initiate a task involving working with food; and after engaging in other activities which contaminated the hands. Review of the facility's P&P titled Sanitation and Infection Control revised 2019 under the section for Handwashing, showed handwashing after handling carts, soiled dishes, and utensils and under the section for Use of Disposable Gloves, showed to wash hands when changing gloves. Review of the facility's P&P titled Dishwashing Procedures - Dish Machine revised 2019 showed to prevent cross-contamination, it is recommended that two employees handle dish washing. One employee will handle soiled dishes and the other employee will handle clean dishes. If only one employee is available to wash and handle clean and soiled dishes, the employee must wash hands thoroughly before handling clean dishes. On 12/9/22 at 0825 hours, Dietary Aide 2 was observed wearing gloves and washing the cups and bowls. Then Dietary Aide 2 was observed removing his gloves and donning new pair of gloves without washing his hands. Dietary Aide 2 proceeded to take a tray full of plates from the dishwasher. On 12/9/22 at 0846 hours, Dietary Aide 2 verified he did not wash his hands when he changed his gloves and between handling dirty and clean dishes. On 12/9/22 at 0858 hours, an interview was conducted with the DSS. The DSS stated Dietary Aide 2 should have washed his hands between handling dirty and clean dishes, and between glove changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 48 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 2. Review of the facility's P&P titled Labeling: Food (undated) showed the following: Level of Harm - Minimal harm or potential for actual harm - Food that is cooked or open and placed into refrigerator will be labeled with name of food item and date placed in the refrigerator; Residents Affected - Some - Items in refrigerator opened will be properly covered, dated and labeled; - Other items that are in original container and opened will have open date labeled. On 12/7/22 at 0750 hours, an initial tour was conducted with the DSS. During the initial tour, the following items in the refrigerator were observed opened and no opened date: - A bottle of caramel sauce; - A bottle of white chocolate sauce; and - A bottle of chocolate sauce. The following items in the open storage area near the stove were observed opened and no opened date: - A bottle of red shade food color; - A bottle of kitchen bouquet browning and seasoning sauce; and - A container of grilling food release spray - opened, undated The DSS verified the findings and stated the food items should have been properly labeled and dated with open dates. 3. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. On 12/9/22 at 1000 hours, a pureed food preparation observation and concurrent interview was conducted with the Cook. After blending the beef goulash, the [NAME] was observed washing the blender. The blender was observed wet. The [NAME] placed the wet blender into the machine. The [NAME] stated he would prepare the pureed carrots. The [NAME] verified the blender was still wet, and stated the blender needed to be air-dried. 4. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, 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 durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 49 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 On 12/9/22 at 0825 hours, bowls and plates were observed stacked and stored on the shelf near the trayline area. Several plates were observed with chipped edges. The DSS verified the above findings. The DSS stated they do not use those plates but would discard the plates. Residents Affected - Some 5. According to the USDA Food Code 2017, 4-501.18, Warewashing Equipment, Clean Solutions, failure to maintain clean wash, rinse, and sanitizing solutions adversely affects the warewashing operation. Equipment and utensils may not be sanitized, resulting in subsequent contamination of food. Review of the Product Technical Fact Sheet for the chlorine test papers showed the shelf-life of the test strip is two years from the date of manufacture when stored properly in the original packaging. According to https://www.preclaboratories.com/knowledge-base/knowledge-base-general-questions/, under Knowledge Based General Questions, the test strips have a minimum shelf-life of two years when stored and handled correctly. In reality, the strips are stable for much longer. We have experienced test strips over 3 years old that still perform to specification. We suggest the test strips be used within one year from the date of opening, given proper storage and handling. On 12/9/22 at 0846 hours, an observation of sanitation bucket test was conducted with Dietary Aide 2. Dietary Aide 2 checked the concentration of the sanitizer using a piece of paper strip taken from a container of chlorine test paper. The chlorine test paper container had an expiration date of 9/2022, with no opened date. Dietary Aide 2 verified the had expired and no opened date 6. According to the USDA Food Code 2017, 3-304.14, Wiping Cloths, Use Limitation, cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution. According to the USDA Food Code 2017, 4-701.10, Food Contact Surfaces and Utensils, effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. Review of the manufacturer's Safety Information on pH Test Papers/Strips (undated) showed the pH test papers have a shelf life of three years and should be stored dry and protected from sunlight. According to https://www.microessentiallab.com/help.aspx, under Frequently Asked Question, the shelf life of the pH test paper is three years from the date of manufacture. The color chart is marked with the expiration and lot number for that specific roll. The pH paper will remain accurate until the expiration date listed. On 12/9/22 at 0840 hours, an observation of sanitation bucket test was conducted with Dietary Aide 1. Dietary Aide 1 checked the concentration of the sanitizer using a paper strip taken from a roll of pH test strips. The pH test strip container had an expiration date of 3/1/22. On 12/9/22 at 0858 hours, an interview was conducted with the DSS. The DSS verified the chlorine test paper container had expired and had no opened date; and the pH test strip roll had expired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 50 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 Cross reference to F802. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 51 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to dispose and store the trash in a sanitary manner. Three of four dumpster were observed overflowing with trash which prevented the lids from fully closing. This failure had the potential to harbor pests and for pest contamination. Residents Affected - Some Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. On 12/8/22 at 1020 hours hours, an observation of the trash disposal and concurrent interview was conducted with the Maintenance Supervisor. Three of the four dumpsters were observed over filled with bags of trash, preventing the lids from closing. The Maintenance Supervisor verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 52 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and medical record review, the facility failed to ensure the medical records for five nonsampled residents (Residents 5, 29, 38, 50, and 95) were accurate or safeguarded. * Resident 38 and 95's medications were documented as administered although the medications were omitted and unavailable. This had the potential for the resident care needs not being met as their medical information was inaccurate. * The facility failed to ensure the resident-identifiable information and medical record information were safeguarded. The facility failed to ensure a laptop displaying the residents' medical record information were safeguarded when left unattended. This had the potential of unauthorized staff and/or visitors' access to residents' confidential medical or personal information. * The facility failed to document on Residents 5, 29, and 50's Controlled Drug Record when medications were removed from the medication supply pack. These had the potential for discrepancy in controlled medication count sheet. Findings: 1. Medical record review for Resident 95 was initiated on 12/8/22. Resident 95 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/8/22 at 0818 hours, a medication administration observation for Resident 95 was conducted with LVN 1. LVN 1 was found to have omitted administering 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) to Resident 95. However, review of Resident 95's Medication Administration Record dated December 2022 showed the 30 ml of UTI-Stat was documented as administered to Resident 95 on 12/8/22 at 0900 hours. On 12/8/22 at 1018 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified UTI-Stat was not administered to Resident 95 because the medication was not available. Cross reference to F759, example #1. 2. Medical record review for Resident 38 was initiated on 12/8/22. Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/8/22 at 0857 hours, a medication administration observation for Resident 38 was conducted with LVN 7. LVN 7 was found to have omitted administering 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) to Resident 38. However, review of Resident 38's Medication Administration Record dated December 2022 showed the 30 ml of UTI-Stat was documented as administered to Resident 38 on 12/8/22 at 0900 hours. On 12/8/22 at 1022 hours, an interview and concurrent medical record review was conducted with LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 53 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Minimal harm or potential for actual harm Residents Affected - Few 7. LVN 7 verified the above findings. LVN 7 verified UTI-Stat was not administered to Resident 38 because the medication was not available. Cross reference to F759, example #2. 3. On 12/9/22 at 1330 hours, a laptop on top of a cart was left open and unattended in the hallway, displaying the resident information. A resident and a housekeeping staff were observed passing by the hallway. On 12/9/22 at 1333 hours, an interview was conducted with RN 2. RN 2 verified the laptop was left open and unattended. RN 2 acknowledged the laptop should have been locked to not display the resident information when left unattended. 4. Review of facility's P&P titled Med Pass (undated) under basic procedure Pour-Pass-Chart, showed prepare the med correctly, administer the med correctly, and chart the med pass correctly. Make sure that during the course of med pass: accountable meds are signed out when removed from stock. Review of Resident 5's medical record was conducted on 12/9/22. Resident was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Review of Resident 5' Order Summary Report showed a physician order dated 9/18/18 to administer phenobarbital solution 20 mg (medication used to treat seizure) per five ml, give 50 mg by mouth in the morning and 25 ml (100 mg) every night at bedtime. On 12/9/22 at 1536 hours, a controlled medication reconciliation was conducted with LVN 8. Resident 5's Controlled Drug Records for phenobarbital showed the medication was last taken out on 12/8/22 at 2100 hours. LVN 8 stated Resident 5's phenobarbital medication was given 12/9/22 at 0900 hours but did not sign the controlled medication count sheet when the medication dose was removed. Review of Resident 5's December 2022 MAR showed the phenobarbital medication ordered was administered on 12/9/22 at 0900 hours. 5. Review of Resident 29's medical record was conducted on 12/9/22. Resident was admitted to the facility on [DATE]. Review of Resident 29's Order Summary Report showed a physician order dated 11/3/22, to administer hydrocodone-acetaminophen five-325 mg (pain medication) one tablet by mouth every six hours as needed for moderate to severe pain. On 12/9/22 at 1538 hours, a controlled medication reconciliation was conducted with LVN 8. Resident 29's Controlled Drug Record for hydrocodone/acetaminophen showed two tablets were remaining. Review of Resident 29's December 2022 MAR showed Resident 29's hydrocodone/APAP was administered at 0900 hours. 6. Review of Resident 50's medical record was conducted on 12/9/22. Resident was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Review of Resident 50's Order Summary Report showed a physician order dated 8/15/22, to administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 54 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 - Minimal harm or potential for actual harm Residents Affected - Few Lyrica capsule 75 mg (pregabalin) (medication used to treat nerve pain), give one capsule by mouth three times a day. On 12/9/22 at 1538 hours, a controlled medication reconciliation was conducted with LVN 8. Resident 50's Controlled Drug Records showed Resident 50's pregabalin medication was last taken out on 12/8/22 at 1700 hours. LVN 8 stated two doses of pregabalin was adminsitered to Resident 50 on 12/9/22 but did not sign the controlled medication count sheet right away. Review of Resident 50's December 2022 MAR showed pregabalin 75 mg was administered on 12/9/22 at 0900 and 1300 hours. On 12/14/22 at 0933 hours, an interview with the ADON was conducted. When asked regarding Resident 50's controlled medications administration, the ADON stated when the controlled medications was given, it has had to be signed right away in Controlled Drug Record to avoid missing medication or discrepancy in the controlled medication count sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 55 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control interventions to reduce the transmission of infectious diseases were followed for three residents (Residents 458, 67, and 92). This failure put the residents at risk for transmission of infection in an already highly susceptible population. Residents Affected - Few Findings: Review of the facility's P&P titled Policy: Enhanced Standard Precaution (undated) showed the enhanced standard precaution is an infection control intervention designed to reduce transmission of multidrug organisms (MDROs). Enhanced barrier precautions involved gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Residents assessed for the need of enhanced barrier precaution include residents with MDRO, those with a feeding tube, and ventilator-dependent residents. Wear gowns and gloves while performing the following tasks associated with the greatest risk for MDRO contamination: - morning and evening care - device care, for exampled feeding tube - any activity where close contact with the resident is expected to occur such as bathing - changing bed linens Review of the facility's document (sign/poster) titled Enhanced Barrier Precautions showed the providers and staff must wear gloves and a gown for the following high contact resident care activities: - bathing, showering - changing linens - device care or use including feeding tube 1. On 12/8/22 at 0856 hours, a medication administration observation and concurrent interview was conducted with LVN 2. LVN 2 prepared the medications for Resident 458 to be administered via GT outside Resident 458's room. A sign showing Enhanced Barrier Precautions was posted near the resident's door. LVN 2 prepared each medication, and then donned gloves prior to administration of the medications. LVN 2 did not don a gown. LVN 2 checked the placement and residual of Resident 458's GT, and then administered all of the medications via the GT. When asked why the sign was posted outside Resident 458's room, LVN 2 stated because she had a GT. LVN 2 stated he should have worn a gown for the administration of the medications via resident's GT. Medical record review for Resident 458 was initiated on 12/8/22. Resident 458 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 458's History and Physical examination dated 9/17/22, showed Resident 458 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 56 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 GT in place. Level of Harm - Minimal harm or potential for actual harm 2. On 12/8/22 at 0957 hours, a medication administration observation and concurrent interview was conducted with LVN 3. During the observation, CNA 1 was observed across the hall inside Resident 67's room. CNA 1 was changing the linens of the bed. CNA 1 was wearing a surgical mask and gloves, but no gown. An enhanced barrier precautions sign was posted next to the door. Resident 67 was observed inside the room in a shower chair, covered with blankets. After disposing the linens, CNA 1 began to push Resident 67 out of the room towards the hallway. CNA 1 was asked where she was going. CNA 1 stated she was taking Resident 67 to the shower room. CNA 1 was asked if she wore a gown while changing the linens or while being in contact with Resident 67, and she stated no, but she knows she was supposed to because Resident 67 had a GT. Residents Affected - Few Medical record review for Resident 67 was initiated on 12/8/22. Resident 67 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 67's History and Physical examination dated 8/27/22, showed Resident 67 had a GT in place. 3. On 12/7/22 at 0845 hours, during the initial tour of the facility, an Enhanced Barrier Precautions sign was observed posted outside of Resident 92's room alerting anyone entering the room to don gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. CNA 5 was observed providing ADL care to Resident 92 without having donned a PPE gown. Following the observation, an interview was conducted with CNA 5. CNA 5 verified the findings. CNA 5 stated he cleaned Resident 92, changed the resident's gown and linen, and repositioned the resident. CNA 5 verified he should have donned a gown prior to providing ADL care to Resident 92. Medical record review for Resident 92 was initiated on 12/7/22. Resident 92 was admitted to the facility on [DATE]. Review of the physician's order dated 12/7/22, showed Resident 92 was in contact isolation for CRE (carbapenem-resistant Enterobacterales, strains of bacteria that are resistant to the antibiotic class carpabenem used to treat severe infections) in the sputum. On 12/13/22 at 0832 hours, an interview was conducted with the IP. The IP verified the staff should don the appropriate PPE when entering Resident 92's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 57 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/7/22 at 0845 and 1127 hours, and on 12/13/22 at 0831 and 0939 hours, Resident 48 was observed lying in bed with bilateral side rails elevated by the head of the bed. On 12/14/22 at 1041 hours, an interview and concurrent facility record review was conducted with the Maintenance Assistant Supervisor. Review of the Bed Safety Checklist for Residents with Side Rails dated 12/7/22, showed no measurements were obtained for entrapment Zone 4 (under the rail at the ends of the rail) for Resident 48 and all other residents with side rails. The Maintenance Assistant Supervisor verified the findings and stated he confused Zone 4 with Zone 5 (between two split side rails). The Maintenance Assistant Supervisor stated the measurements documented on the Bed Safety Checklist for Residents with Side Rails were obtained three years ago or so based on a standard sized mattress and the bed. When asked if new measurements were conducted when standard sized mattresses were switched to a different type of mattress like the low air low mattress, the Maintenance Assistant Supervisor stated no because they are not informed if or when the residents' mattress types were changed. On 12/14/22 at 1205 hours, an interview was conducted with LVN 9. LVN 9 stated the nurses did not inform the maintenance staff if or when the residents' mattresses were changed. Based on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Policy for Resident's Bed Entrapment (undated) showed the following: - The facility will conduct inspection of all bed frames, mattresses, and bedrails to identify areas of possible entrapment to ensure safety; and - The facility will utilize 7-zone as reference for bed entrapment assessment. According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 58 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0909 - Zone 3: between the rail and the mattress; Level of Harm - Minimal harm or potential for actual harm - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; Residents Affected - Some - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's document titled Bed Safety Checklist for Residents with Side Rails dated 12/7/22, showed there were 108 residents and Zones 1, 2, 3, 5, 6, and 7 were inspected. The column for Zone 4 showed N/A. The document showed Zone 4 was not inspected for possible entrapment. Further review of the residents' medical records and facility document showed the residents beds in the facility were not properly inspected for possible entrapment. For example: 1. On 12/7/22 at 0918, 0929, and 0948 hours, on 12/8/22 at 0827, 1335, and 1525 hours, and on 12/13/22 at 0935 hours, Resident 359 was observed in bed. Resident 359 had 1/4 side rails up on the left side of the bed. Resident 359 was observed leaning towards the left, and his head was near the left side rail. Medical record review for Resident 359 was initiated on 12/7/22. Resident 359 initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 359's Order Summary Report showed a physician's order dated 11/21/22, for bilateral upper half side rails when in bed for safety and protection secondary to involuntary movement. Review of Resident 359's plan of care showed a care plan problem dated 2/20/19, to address safe bed, and to provide resident with a bed that reduces hazards such as entrapment associated with use of hospital beds and side rails. The interventions included to inspect all beds upon admission and/or bed changes, bed frame, side rails mattress type. 2. On 12/7/22 at 0829, 0831, and 0847 hours, on 12/8/22 at 0829, and 0922, 0928, 1220 and 1332 hours, and on 12/9/22 at 0840, 1244, 1247, and 1337 hours, Resident 17 was observed lying in bed with bilateral upper side rails elevated. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 43's Order Summary Report showed the following physician's order dated 10/27/22, for bilateral upper half side rails up and locked when in bed as enabler for positioning and ease of mobility; and on 10/28/22, for low air loss mattress for wound care and management. On 12/14/22 at 0855 hours, an interview was conducted with the Maintenance Supervisor. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 59 of 60 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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 0909 Level of Harm - Minimal harm or potential for actual harm about the bed inspection, the Maintenance Supervisor stated bed inspections should be done monthly, however, they have not done the monthly bed inspection for this month. When asked what the process was for the monthly bed inspection, the Maintenance Supervisor stated he was new in the position, but the Maintenance Assistant Supervisor had done it before. The Maintenance Supervisor was asked to provide documentation of their recent bed inspection. Residents Affected - Some On 12/14/22 at 1040 hours, an interview and concurrent facility document review for bed inspection was conducted with the Maintenance Assistant Supervisor. When asked about the bed inspection process, the Maintenance Assistant Supervisor stated he checked if there was a gap between the mattress and the side rails. When asked why it was necessary to check the beds prior to the installation of bed rails, the Maintenance Assistant Supervisor stated the resident could get stuck in between the bed and rail. When asked why zone 4 was documented as N/A on the Bed Safety Checklist form, the Maintenance Assistant Supervisor stated N/A meant not applicable, and he did not measure the zone 4 on the bed because the residents only used the upper bilateral side rails. When asked if he measured the different zones on the beds for 108 residents on 12/7/22, the Maintenance Assistant Supervisor stated he only visually inspected the beds. The Maintenance Assistant Supervisor stated the measurements were done three to four years ago based on a standard bed and a regular mattress. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment are present based on the change of the bed, or mattress, or user, the Maintenance Assistant Supervisor answered no. The Maintenance Assistant Supervisor stated he was not informed when a resident switched bed or mattress. The Maintenance Assistant Supervisor stated he did not know he had to inspect the bed for possible entrapment each time there was a change of bed, mattress or resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 60 of 60