Health inspection·November 18, 2021

F 0656 Level of Harm - Potential for minimal harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 17 final sampled residents (Resident 205). *The facility failed to develop a care plan to address Resident 205's use of continuous oxygen. This failure had the potential to negatively impact the care needed for the residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised on 9/25/19, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Findings: On 11/15/21 at 0758 hours, during the initial tour, Resident 205 was observed asleep in bed with continuous oxygen at 2 liters per minute. Medical record review for Resident 205 was initiated on 11/15/21. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 11/10/21, for oxygen 2 liters per minute via nasal cannula at all times for SOB except during ADL care every shift. Review of the plan of care failed to show a care plan problem addressing Resident 205's use of continuous oxygen for SOB. On 11/17/21 at 1138 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no care plan developed for the oxygen use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 2 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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, medical record review, and facility P&P review, the facility failed to provide an environment free from accident hazards for one of 17 final sampled residents (Resident 10). * The facility failed to ensure safe smoking practice for Resident 10 who smoked in the facility. Resident 10 had her smoking materials in her possession when her care plan for safe smoking included the intervention for the activity staff to keep her lighter and the facility's smoking policy showed the smoking materials were to be maintained by staff. This failure posed the risk of fire and injury to the residents and staff in the facility. Findings: Review of the facility's P&P titled Resident Smoking Policy revised 3/27/17, showed the smoking materials of residents will be maintained by staff. Review of Resident 10's medical record was initiated on 11/5/21. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 10 was cognitively intact but needed extensive assistance with her ADL care. Review of Resident 10's IDT Assessment of Smoking dated 9/15/21, showed Resident 10 was able to smoke independently with the staff's supervision. There was no documentation to show Resident 10 could keep her cigarette lighter. Review of the Smoking Agreement dated 9/15/21, showed Resident 10 understood the facility's smoking policy. There was no documentation Resident 10 could keep her cigarette lighter. Review of the Resident Smoking Care plan showed a care plan problem addressing Resident 10's smoking safety initiated on 9/15/21. Interventions included to keep Resident 10's cigarette lighter with the activity staff for scheduled smoking time. On 11/15/21 at 1127 hours, an interview was conducted with Resident 10. Resident 10 stated she kept her cigarettes and lighter in her pink purse. Resident 10 stated she went out to smoke whenever the staff was available. On 11/17/21 at 1025 hours, a concurrent observation, interview and medical record review was conducted with the Activity Director. The Activity Director stated Resident 10's lighter was kept in the activities office. The Activity Director stated she kept three lighters for Resident 44. The Activity Director stated she was aware Resident 10 had a cigarette lighter with her. The Activity Director stated that was Resident 10's right. When asked to show Resident 10's ability to keep her smoking materials, the Activity Director verified the Smoking Assessment and Smoking Agreement did not show Resident 10 could keep the smoking material. The Activity Director verified Resident 10's care plan showed an intervention for the activity staff to keep Resident 10's cigarette lighter. The Activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 3 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Director verified Resident 10 had a lighter in her purse. The Activity Director stated it was possible Resident 10 got the cigarette lighter from someone at the hospital before she was readmitted to the facility. On 11/17/21 at 1430 hours, an interview and concurrent medical record review was conducted with the DON. When asked how the facility handled the smoking materials of residents who smoked, the DON stated the residents' smoking materials were maintained by the activity staff. The DON stated the residents followed a smoking schedule with a designated area for smoking. The DON was informed Resident 10 had been keeping the cigarettes and lighter. The DON stated Resident 10 should not keep the lighter and cigarettes as per the facility P&P. The DON verified the findings. Event ID: Facility ID: 555141 If continuation sheet Page 4 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 review, the facility failed to provide the necessary care and services for the use of a GT for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37 received the accurate amount of enteral feeding as ordered by the physician. In addition, the facility failed to accurately document Resident 37's amount of enteral feeding and water flushed via enteral pump. These failures had the potential for not meeting the resident's nutritional and hydration needs. Findings: According to the facility's P&P titled Tube Feeding,Naso-Gastric, Gastrostomy, Jejunostomy, via Enteral Pump revised on 7/8/21, showed it is the policy of the facility to properly monitor Naso-Gastric, Gastrostomy, Jejunostomy feedings to provide nourishment, administer medication, and to maintain hydration. Medical record review for Resident 37 was initiated on 11/15/21. Resident 37 was admitted to the facility on [DATE]. Review if the MDS dated [DATE], showed Resident 37 had severe cognitive impairment. Resident 37 was totally dependent on staff for her ADL care. Resident 37 had a feeding tube. Review of Resident 37's Order Summary Report showed a physician's order dated 10/5/21, to administer Glucerna (enteral feeding formula) 1.2 at 60 ml/hour for 20 hours to provide 1200 ml/1440 kcals, starting at 1300 hours and continue until 0900 hours or until the volume was given and record the time dosage was completed. Another physician's order dated 10/4/21, showed to flush Resident 37's GT with water at 50 ml/hour for 20 hours to provide 1000 ml of water/day, starting at 1300 hours and continue until 0900 hours or until the volume was given in the afternoon. a. On 11/18/21 at 0721 hours, Resident 37 was observed receiving Glucerna 1.2 cal via a feeding pump. Resident 37's Glucerna 1.2 feeding bottle had 1400 ml of formula left in the bottle. Resident 37's Glucerna 1.2 feeding bottle label showed a full bottle contained 1.5 L (1500 ml), with a date written as 11/18/21, start time of 0100 hours, and rate of 60 ml per hour. Resident 37's Glucerna 1.2 feeding bottle was hung at 0100 hours, therefore, a total of 6 hours had passed. However, Resident 37 had received only 100 ml (1500 ml less 1400 ml) instead of the 360 ml (60 ml/hour x 6 hours) as prescribed by the physician. On 11/18/21 at 0822 hours, a concurrent interview and facility record review was conducted with the DON and LVN 3. LVN 3 verified Resident 37's Glucerna 1.2 full feeding bottle (1500 ml) had a label which showed it was started on 11/18/21 at 0100 hours. LVN 3 stated she hung Resident 37's Glucerna 1.2 cal at 0100 hours. The DON and LVN 3 verified Resident 37's Glucerna 1.2 bottle had 1400 ml of formula left in the bottle at 0721 hours. The DON and LVN 3 acknowledged Resident 37 had received only 100 ml for the past 6 hours instead of 360 ml (60 ml x 6 hours) as prescribed by the physician. The DON and LVN 3 stated there should have been 1140 ml of formula left in the Glucerna bottle instead of 1400 ml. Cross reference to F726. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 5 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 b. According to the facility's P&P titled Enteral Intake Recording revised 3/11/02, showed fluid intake shall be recorded for each resident with enteral feeding tubes as prescribed by the physician. This shall be recorded and monitored each shift by a Licensed Nurse. The intake information is to be recorded at the end of each shift by a Licensed Nurse. Residents on enteral pumps, intake total for the day shall be recorded at the end of feeding cycle shift and the 24-hour total is to be entered by the end of feeding cycle shift. Residents Affected - Few Review of Resident 37's G-Tube Intake and Output Form dated 11/2021, showed the following: - On 11/4/21 for the 7-3 shift, 1300 ml of formula and 950 ml of water - On 11/5/21 for the 7-3 shift, 1400 ml of formula and 650 ml of water - On 11/6/21 for the 7-3 shift, 1500 ml of formula and 900 ml of water - On 11/15/21 for the 7-3 shift, 876 ml of formula and 724 ml of water On 11/18/21 at 0822 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 37 had a physician's order to receive a total of 1200 ml/day of Glucerna 1.2 and a total of 1000 ml of water for 20 hours. The DON stated the licensed nurses working on the 7-3 shift were responsible in documenting Resident 37's total formula and water intake. The DON verified the amounts of formula and water that Resident 37 had received was not accurately reflected in the GT intake and output for November 2021. The DON verified the amounts of formula and water documented in Resident 37's GT intake and Output were either more or less than the amount prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 6 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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** 2. On 11/15/21 at 0807 hours, during the initial tour, Resident 30 was observed receiving oxygen at 2 liters per minute via nasal cannula. Residents Affected - Few Medical record review for Resident 30 was initiated on 11/15/21. Resident 30 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 10/7/21, for oxygen at 3 liters per minute via nasal cannula at all times for SOB except during ADL care. On 11/16/21 at 1019 hours, a concurrent observation and interview was conducted with LVN 5 for Resident 30. Resident 30 received oxygen at 2 liters per minute via nasal cannula. LVN 5 verified Resident 30's oxygen level was only at 2 liters per minute. LVN 5 verified Resident 30's oxygen rate was supposed to be at 3 liters per minute as ordered by the physician. LVN 5 stated she did not check Resident 30's oxygen at the beginning of shift and was not aware of the resident receiving only 2 liters per minute. When LVN 5 was asked what potentially could happen to Resident 30, LVN 5 stated Resident 30 could develop SOB and have a low oxygen saturation level. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory care needs to two of 17 final sampled residents (Residents 30 and 44). * The facility failed to ensure Resident 44's oxygen therapy titration (adjusting oxygen level) based on her oxygen saturation level (percentage of oxygen in the blood with normal levels of 95% and higher) was monitored and documented in the medical record. * The facility failed to ensure Resident 30's oxygen was administered as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the improper care and administration of oxygen. Findings: According to the facility's P&P titled Oxygen Therapy Misty Oxygen revised on 5/8/2017, showed oxygen therapy is administered as ordered by the physician. The licensed nurses will set the oxygen flow rate as ordered. Documentation will include the date and time of oxygen in use, oxygen flow rate and device being use, and assessment of the resident's response to therapy. 1. Medical record review for Resident 44 was initiated on 11/15/21. Resident 44 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report dated 10/24/21, show the physician's orders dated 10/12/21, to administer oxygen 2 liter per minute via nasal cannula at all times for SOB except during ADL care every shift and monitor the oxygen saturation levels to maintain greater or equal of 92 % every shift. The licensed nurses may titrate up to four liters and document on the reverse page of MAR. Review of the MAR for November 2021 showed Resident 44's oxygen saturation levels ranged from 92-99% for all shifts. There was no documentation to show Resident 44's oxygen was titrated to maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 7 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 oxygen saturation level at 92% and higher. Level of Harm - Minimal harm or potential for actual harm Review of the Nursing Progress Notes for the month of November 2021 did not show any documentation when Resident 44's oxygen level was titrated to maintain the oxygen saturation level at 92% and higher. Residents Affected - Few On 11/15/21 at 1257 hours, Resident 44 was observed having lunch in bed and receiving oxygen therapy at 3.5 liters per minute via nasal cannula. On 11/16/21 at 0855 hours, Resident 44 was observed having breakfast in bed and receiving oxygen therapy at 3.5 liters per minute via nasal cannula. On 11/16/21 at 1030 hours, a concurrent observation, interview, and medical record review was conducted with LVN 1. LVN 1 verified Resident 44 was currently receiving oxygen at 4 liters per minute. LVN 1 stated Resident 44 had a physician order for oxygen at 2 liters per minute. LVN 1 stated when Resident 44 had episodes of SOB and when the oxygen saturation level less than 92%, the oxygen rate would be titrated up to 4 liters per minute. When asked how Resident 44's titration information and the assessment of the response to the oxygen therapy, LVN 1 stated the nurses had to document the oxygen titration on the back of MAR. When asked to show the documentation, LVN 1 verified there was no documentation of oxygen titration rate in the MAR for November 2021 for Resident 44. LVN 1 acknowledged there was also no documentation in Resident 44's progress notes for the oxygen therapy titration based on the resident's oxygen saturation level. On 11/16/21 at 1335 hours, an interview and concurrent the facility P&P's review was conducted with the DON. The DON verified the findings. The DON stated whenever the oxygen rate was being titrated as ordered by the physician, the licensed nurse had to document the titration information and the assessment of the resident's response to the oxygen therapy on the back page of MAR or in the nursing progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 8 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had the specific competencies and skill sets needed to care for the residents. Residents Affected - Few * The facility failed to ensure a program was in place to check the competencies and skill sets of the licensed nurses at the facility upon hiring and ongoing basis. The DSD/IP 1, IP 2, LVNs 1, and 4 failed to demonstrate how to obtain the history of the volume of feeding and water flush via the enteral pump for Resident 37. This failure had the potential to put the residents at risk for care not provided in a safe and competent manner. Findings: According to the facility's P&P titled Competency Evaluation dated 4/1/19, showed it is the policy of the facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. According to the operating manual titled Epump Enteral Feed and Flush Pump with Pole Clamp Programable, under the section History in the More Options menu, to access the History screen, press the buttons feed ml and flush ml to show the requested history time. A maximum of 72 hours of past history, excluding data from the current hour can be retrieved. On 11/16/21 at 1033 hours, Resident 37 was observed lying on her bed and receiving Glucerna 1.2 at 60 ml per hour and water at 50 ml of via enteral pump. On 11/16/21 at 1055 hours, an interview was conducted with LVN 1. When asked to demonstrate how to obtain the history of the volume fed and water flushed from Resident 37's enteral pump, LVN 1 stated she did not know how. When asked if she had received any inservices regarding the use of the enteral pump and how to obtain the feeding history, LVN 1 stated no. On 11/16/21 at 1059 hours, an interview was conducted with LVN 4. LVN 4 was asked to demonstrate how to obtain the history of the volume fed and water flushed for the past 24, 48, and 72 hours from the enteral pump for Resident 37. LVN 4 stated she just looked at the enteral pup screen to see how much feeding volume and water were administered . LVN 4 stated she did not know how to obtain the feeding history. When asked if she had received any inservices regarding the use of the enteral pump and how to obtain the feeding history, LVN 4 stated no. On 11/16/21 at 1109 hours, concurrent interviews were conducted with the DSD/IP 1 and IP 2. The DSD/IP 1 and IP 2 were asked to demonstrate how to obtain the history from the enteral pump for Resident 37. The DSD/IP 1 and IP 2 stated they did not know how to obtain the history of volume fed. When the DSD/IP 1 was asked if she had given any inservices regarding the use of the enteral pump and how to obtain history from the enteral pump, she stated not recently. When asked how the facility monitored for the staff's competency, the DSD/IP 1 did not provide further response. When asked how often the facility checked the staff's competency, she stated the competency checks should be every year. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 9 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 0726 Level of Harm - Minimal harm or potential for actual harm On 11/16/21 at 1130 hours, an interview was conducted with the DON. The DON acknowledged the findings. The DON stated the provision of inservices regarding the use of the enteral pump was overlooked. Cross reference to F693. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 10 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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. Based on observation, interview, and facility P&P review, the facility failed to ensure safe medication storage was observed in two of eight medication carts (Treatment Cart 1 and IV Cart 1). * An expired central line (catheter that is placed into a large vein) dressing kit was observed in IV (intravenous) Cart 1. * An expired tube of Remedy cream (moisture barrier cream) was observed in Treatment Cart 1. These failures had the potential for the residents to be exposed to the expired medications. Findings: According to the facility's P&P titled Storage and Expiration dating of Medications, Biologicals, Syringes and Needles, the facility should ensure that medication and biological that have expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 1. On 11/17/2021, at 0828 hours, during the inspection of IV Cart 1 with IP 2, a central line dressing kit with an expiration date of 10/31/21 was found in the middle drawer of the IV Cart 1. IP 2 verified the findings and stated the central line dressing kit should not have been in the IV Cart 1. IP 2 stated the expired central line dressing kit should have been disposed. 2. On 11/17/2021, at 0958 hours, during the inspection of Treatment Cart 1 with LVN 2, a tube of used Remedy cream with an expiration date of 8/2021 was observed in the middle drawer of Treatment Cart 1. LVN 2 verified the findings and stated the Remedy cream should have been disposed. On 11/18/2021 at 1457 hours, an interview was conducted with the DON. The DON stated the expired central line dressing kit and tube of Remedy cream should have been disposed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 11 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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, and facility P&P review, the facility failed to ensure the proper infection control measures were implemented as evidenced by: Residents Affected - Few * LVN 1 did not perform hand hygiene when preparing Resident 207's medications. * The facility failed to ensure aseptic technique was observed during the preparation of Resident 207's heparin (medication to prevent the formation of the blood clot) medication. LVN 1 did not disinfect the self-sealing rubber topper of the medication vial with an antimicrobial swab each time she attempted to withdraw the heparin medication. LVN 1 used the same needle and syringe multiple times to withdraw the medication from the heparin vial. These failures had the potential to result in the transmission of infection for the resident. Findings: 1. Review of the facility's P&P titled Hand Hygiene revised on 04/27/21, showed the staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. On 10/16/21 at 0853 hours, a medication administration observation for Resident 207 was conducted with LVN 1. LVN 1 was observed preparing Resident 207's medications. LVN 1 dropped the following medications on the floor: - one lidocaine 4% patch ( medication to help reduce pain) - a syringe of one ml of heparin - one Dulera inhaler (a medication to treat asthma) LVN 1 picked up the above medications and discarded them. Without performing hand hygiene, LVN 1 then proceeded to prepare Resident 207's medications. LVN 1 removed one lidocaine patch from a sealed packet, then opened a syringe and withdrew the heparin medication. LVN 1 did not disinfect the Dulera inhaler. LVN 1 entered Resident 207's room and administered the medications without performing hand hygiene. On 10/16/2021, at 1423 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she did not perform hand hygiene after she picked up Resident 207's medications from the floor and prior to preparing the new set of medications. On 11/17/2021, at 1512 hours, an interview was conducted with the DON. The DON stated LVN 1 should have performed hand hygiene after picking the medications from the floor and before entering the resident's room to administer the medications. 2. According to the Fundamentals of Nursing by [NAME], seventh edition, under the section Removing Medication from a Vial (a glass bottle with self sealing stopper through which a medication is removed), after the initial use of the multidose vial (contains multiple doses of medications), to wipe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 12 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 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 the rubber topper with alcohol each time the medication is removed from the vial. Level of Harm - Minimal harm or potential for actual harm According to the Centers for Disease Control and Prevention (CDC) FAQs regarding Safe Practices for Medical Injections, injection safety or safe injection practices is a set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel and others. Under the section Medication Preparation Questions showed the staff should adhere to aseptic technique (using practices and procedures to prevent contamination from microorganisms) when preparing the medications. A new sterile syringe and sterile needle is used to draw up medications while preventing contact between the injection materials and the non sterile environment. The rubber septum of vials should be disinfected with alcohol prior to piercing it. Residents Affected - Few According the CDC's One and Only Campaign - Injection Safety Checklist, medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient. On 11/16/2021, at 0853 hours, during medication administration observation with LVN 1, LVN 1 was observed preparing Resident 207's heparin injection. Without performing hand hygiene, LVN 1 took a 1 ml syringe from a sterile packet, cleansed the self sealing topper of the mutlidose heparin vial using an alcohol wipe, pierced the self sealing topper with the syringe needle, and attempted to withdraw one ml of heparin. When LVN 1 was not able to withdraw the desired amount of heparin solution, LVN 1 then removed the needle from the vial, tapped the syringe to remove the air inside, and then reinserted the same needle back into the self sealing topper. LVN 1 did not clean the self sealing topper prior to resinserting the needle. LVN 1 attempted to remove the medication from the heparin vial multiple times using the same syringe and needle without cleaning the self sealing topper with an antimicrobial swab each time. On 11/16/2021 at 1423 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she inserted the same needle into the heparin vial multiple times. LVN 1 acknowledged she did not clean the self-sealing topper of the medication vial with antimicrobial swab each time she reinserted the same needle into the heparin vial to withdraw the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 13 of 14 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 555141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town & Country 555 East Memory Lane Santa Ana, CA 92706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the risks and benefits of influenza vaccination were reviewed with the resident for one of 17 final sampled residents (Resident 52) when Resident 52 refused the influenza vaccine. This failure had the potential for the resident not being informed of the benefits and risks of influenza vaccination to make an informed decision. Residents Affected - Few Findings: Medical record review for Resident 52 was initiated on 11/17/21. Resident 52 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 10/25/21, showed Resident 52 had the capacity to understand and make decision. Review of the Nursing admission assessment dated [DATE], showed Resident 52 refused the influenza vaccine. Further review of the medical record failed to show any documentation Resident 52 was provided education on the risks and benefits of influenza vaccine. On 11/17/21 at 1012 hours, a concurrent interview and medical record review was conducted with IP 2. IP 2 verified there was no documentation to show Resident 52 was provided the education on the risks and benefits when he refused the influenza vaccine. IP 2 stated the purpose of the vaccine education was to help Resident 52 making an informed decision regarding the influenza vaccine. On 11/17/21 at 1457 hours, an interview was conducted with the DON. The DON stated even if a resident refused the influenza vaccine, there should have been documentation of the influenza vaccine education provided to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 14 of 14