Health inspection·November 22, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 3's sling was not applied properly and should be applied around Resident 3's right forearm, with the straps placed around Resident 3's posterior neck to provide support for his right arm. On 11/20/23 at 1317 hours, an interview was conducted with RN 1. RN 1 stated he was aware Resident 3 had a physician's order for a sling to be applied on his RUE. However, RN 1 stated he did not have the chance to check whether Resident 3's sling was on and applied properly on his RUE. On 11/22/23 at 0913 hours, an interview was conducted with the ADON. The ADON was informed and acknowledged the above finding. The ADON stated the licensed nurses were expected to apply the sling as ordered by the physician and to monitor for proper application and placement of the sling during their shift. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 2 of 8 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 11/22/2023 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, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote the healing of existing pressure injuries for two of three sampled residents (Residents 1 and 2). Residents Affected - Few * The facility failed to provide the appropriate and necessary nursing services to ensure Residents 1 and 2 had no more than two layers of linen between the residents and low air loss mattress. This failure had the potential of Residents 1 and 2 not receiving the appropriate care and services to promote healing or prevent the development of new pressure injuries. Findings: Review of the facility's P&P titled Pressure-reducing Mattresses (undated) showed the objective of the policy was to provide mattresses that will prevent and/or minimize pressure on the skin. Under the section for Steps showed to place a flat sheet over the mattress, while ensuring that no more than two layers of linen are between the resident and the pressure-reducing mattress. If the resident is incontinent, place protective pad in the center of the bed, this will count as one layer of linen. 1. During the initial tour of the facility on 11/20/23 at 1021 hours, Resident 1 was observed lying on a LAL mattress covered with a flat sheet and two protective pads were underneath Resident 1. Medical record review for Resident 1 was initiated on 11/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderately impaired cognition and required maximal assistance from staff to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). Review of Resident 1's Skin Progress Report dated 11/14/23, showed Resident 1 had a Stage 4 (full-thickness skin loss with exposed bone, tendon, or muscle) pressure injury to her sacrococcygeal (pertaining to both the sacrum and coccyx/tailbone) extending to the left and right buttocks and right ischium (forms the lower and back part of the hip bone). On 11/20/23 at 1209 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 1 was lying on a LAL mattress covered with a flat sheet and two protective pads were underneath the resident who was also wearing an incontinence brief. On 11/20/23 at 1425 hours, a wound care observation for Resident 1 was conducted with LVN 1 and the IP. The IP verified Resident 1 was lying on a LAL mattress covered with a flat sheet and one protective pad was underneath the resident who was also wearing an incontinence brief. The IP stated Resident 1 should only have either a protective pad or an incontinence brief when lying on a LAL mattress covered with a flat sheet. The IP stated there should only be two layers between the LAL mattress and resident. 2. On 11/20/23 at 1135 hours, an observation and concurrent interview was conducted with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 3 of 8 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 11/22/2023 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 2. Resident 2 was observed lying on a LAL mattress covered with a flat sheet and two protective pads were underneath the resident who was also wearing an incontinence brief. Medical record review for Resident 2 was initiated on 11/20/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Residents Affected - Few Review of Resident 2's H&P examination dated 10/4/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 was at risk of developing pressure ulcers/injuries. The MDS showed Resident 2 had an unstageable (full thickness skin loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar/ dead tissue) pressure injury. On 11/20/23 at 1208 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 2 was lying on a LAL mattress covered with a flat sheet and two protective pads were underneath the resident who was wearing an incontinence brief. LVN 1 stated there should only be two layers between the resident and the LAL mattress. LVN 1 stated the protective pad and incontinence brief were considered one layer each. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 4 of 8 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 11/22/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure one of three sampled residents (Resident 3) who received enteral feedings via GT were provided the appropriate treatment and services to prevent complications. * The facility failed to ensure Resident 3 was administered the correct enteral feeding formula as ordered by the physician. In addition, the facility failed to ensure the enteral feeding mechanical pump was operated by a licensed staff for Resident 3. These failures posed the potential risk for not meeting the Resident 3's nutritional needs and potential risk for aspiration during feeding. Findings: Review of the facility's P&P titled Enteral Feedings- Safety Precautions revised 11/2018 showed the purpose of the policy is to ensure the safe administration of enteral nutrition. Under the section Preparation showed all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. Under the section Preventing Errors in Administration showed to check the enteral nutrition label against the order before administration. a. Medical record review of Resident 3 was initiated on 11/20/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's History and Physical examination dated 4/11/23, showed Resident 3 had dysphagia (difficulty swallowing) and GT feeding, and did not have the capacity to understand and make decisions. Review of Resident 3's MDS dated [DATE], showed Resident 3 was totally dependent on the staff for eating (including intake of nourishment through tube feeding). Review of Resident 3's Order Summary Report dated 11/22/23, showed a physician's order dated 8/3/23, to administer Glucerna 1.2 (a type of feeding formula) at 80 ml/hr for 20 hours via pump to provide 1600 ml or 1920 kcals. On 11/20/23 at 1236 hours, an observation was conducted with Resident 3. Resident 3 was observed lying on a LAL mattress, positioned on his back with his head of bed elevated. Resident 3 was observed receiving enteral feeding of Jevity 1.2 (a type of feeding formula) at 80 ml/hr via mechanical pump. However, the enteral feeding bottle was labeled with Resident A's name and room number. On 11/20/23 at 1243 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 3 was receiving Jevity 1.2 at 80 ml/hr via mechanical pump. LVN 2 verified the Jevity 1.2 formula bottle was labeled with Resident A's name and room number. On 11/20/23 at 1257 hours, a follow-up observation and concurrent interview was conducted with LVN 2. LVN 2 was observed checking Resident 3's physician's order. LVN 2 verified thephysician's order showed to administer Glucerna 1.2 at 80 ml/hr. LVN 2 stated the Jevity 1.2 formula bottle was hung by the previous licensed nurse. LVN 2 stated he turned on Resident 3's enteral mechanical pump with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 5 of 8 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 11/22/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Jevity 1.2 formula hanging at 1200 hours. However, LVN 2 stated he did not check if the correct enteral feeding formula was hanging prior to turning on the mechanical pump and administering the feeding to Resident 3. On 11/20/23 at 1313 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated he turned off the enteral feeding pump, changed Resident 3's enteral feeding formula to Glucerna 1.2 as ordered by the physician and notified the physician of Resident 3 receiving the wrong feeding formula. b. On 11/20/23 at 1302 hours, an observation and concurrent interview was conducted with CNA 1. Resident 3 was observed lying in bed, positioned on his back with his head of bed elevated and receiving enteral feeding via mechanical pump. CNA 1 was observed pressing the hold button on the mechanical pump and lowering Resident 3's head of bed down to fix the placement of Resident 3's right arm sling. CNA 1 stated he was allowed to put the enteral feeding on hold when he provided care for the resident but would inform the licensed nurse when he was done providing care. On 11/20/23 at 1313 hours, an interview was conducted with LVN 2. LVN 2 stated he was unfamiliar about the facility's policy allowing CNAs to operate the enteral feeding mechanical pump. However, LVN 2 stated CNAs were not allowed to operate the enteral feeding mechanical pump. On 11/20/23 at 1317 hours, an interview was conducted with RN 1. RN 1 stated CNAs should not be operating the enteral feeding mechanical pump, including pressing the hold button when providing care for the resident. On 11/22/23 at 0913 hours, an interview was conducted with the ADON. The ADON was informed and acknowledged the above findings. The ADON stated the licensed nurses were expected to check the enteral feeding formula against the physician's order prior to hanging and administering an enteral feeding formula. The ADON stated CNAs must notify the licensed nurse to put the enteral feeding pump on hold because CNAs were not trained to operate the mechanical pump. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 6 of 8 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 11/22/2023 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, and facility P&P review, the facility failed to ensure the nursing staff performed hand hygiene during the wound care treatment for two of three sampled residents (Residents 1 and 2). This failure posed the risk of infection and the transmission of disease-causing microorganisms. Residents Affected - Few Findings: Review of the facility's P&P titled Hand Washing (undated) showed hand washing must be performed in between performance of routine procedures i.e., handling urinals, bedpans, catheters, changing dressings, collecting specimens, etc. Review of the facility's P&P titled Wound Care revised 3/2023 showed the purpose of the policy is to provide guidelines for the care of wounds to promote healing. Under the section Steps in the Procedures showed: (a) put on exam gloves, loosen tape, and remove dressing, (b) pull gloves over the dressing and discard into appropriate receptacle, (c) wash and dry hands thoroughly, and (d) put on gloves. 1. Medical record review for Resident 1 was initiated on 11/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 11/22/23 showed a physician's order dated 11/14/23, to cleanse the right ischium wound with normal saline, pat dry, apply hydrogel gel (gel that creates a moist wound environment and promotes wound healing) followed by collagen (used to help the body naturally restart the wound healing process) powder topically every day shift. Review of Resident 1's Order Summary Report dated 11/22/23 showed a physician's order dated 11/14/23, to cleanse the sacrococcyx wound extending to left and right buttock with normal saline, pat dry, apply collagen sheet, then cover with a dry dressing every day shift. On 11/20/23 at 1425 hours, a wound care observation for Resident 1 was conducted with LVN 1 and the IP. Resident 1 was observed awake and lying on a LAL mattress. LVN 1 and theIP were observed washing their hands with soap and water and donning a clean pair of gloves and gowns. Resident 1's sacrococcyx, left and right buttocks, and right ischium pressure injuries were observed not covered with a dressing. LVN 1 was observed cleaning Resident 1's wounds with normal saline, then patted them dry with a gauze. LVN 1 then proceeded to apply the collagen sheets to Resident 1's sacrococcyx and left and right buttock wounds without changing his gloves and performing hand hygiene. LVN 1 then covered and secured Resident 1's sacrococcyx extending to the left and right buttock wounds with a bordered dressing. LVN 1 was observed removing his gloves, washing his hands with soap and water, then donning a new pair of clean gloves. Finally, LVN 1 used a tongue depressor to apply hydrogel and collagen powder to Resident 1's right ischium wound. On 11/20/23 at 1440 hours, an interview was conducted with LVN 1 and the IP. LVN 1 and theIP verified the above findings. LVN 1 and the IP stated LVN 1 should have removed his old gloves, washed his hands with soap and water, and donned new gloves after cleaning Resident 1's wounds. 2. Medical record review for Resident 1 was initiated on 11/20/23. Resident 2 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 7 of 8 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 11/22/2023 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 facility on [DATE], and readmitted on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's Order Summary Report dated 11/22/23, showed a physician's order dated 11/14/23, to cleanse status post mid abdominal opened surgical wound with three retention sutures with normal saline, apply wet to dry dressing, and cover with a bordered gauze. Residents Affected - Few On 11/20/23 at 1145 hours, a wound care observation was conducted with LVN 1. Resident was observed being awake and lying on a LAL mattress. LVN 1 was observed washing his hands with soap and water and donning a clean pair of gloves. LVN 1 was observed removing the dressing from Resident 2's mid abdominal wound. LVN 1 then proceeded to clean Resident 2's wound with normal saline, then patted it dry with gauze, without changing his gloves and performing hand hygiene. LVN 1 was then observed changing to a clean pair of gloves, without performing hand hygiene, and used a cotton tipped swab to pack Resident 2's wound with gauze moistened with normal saline. Finally, LVN 1 changed to a clean pair of gloves without performing hand hygiene, and covered Resident 2's wound with a bordered dressing. On 11/20/23 at 1208 hours, an interview was conducted with LVN 1. LVN 1 verified the above findings and stated he should have washed his hands and changed to a clean pair of gloves after removing the old dressing and before donning clean each pair of gloves. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555035 If continuation sheet Page 8 of 8