Health inspection·July 24, 2025

F 0655 care plan should have been initiated for the resident within 48 hours of admission. Cross reference to F684. 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: 555141 If continuation sheet Page 2 of 6 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 07/24/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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, medical record review, and facility P&P review, the facility failed to ensure the care plan was developed for one of three sampled residents (Resident 1) who had a change in condition. * The facility failed to develop a care plan when Resident 1 had nausea, vomiting, poor meal intake, and weight loss. This failure had the potential for Resident 1 to not receive the necessary care and services.Findings: Review facility's P&P titled Resident Change of Condition revised on 5/22/24, showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. The nurse in charge is responsible for the notification of the physician prior to end of the assigned shift when a change in a resident's condition is noted. To document the resident change of condition and response in Nursing Progress Notes, on Twenty-Four Hour Report and update resident care plan as indicated. Closed medical record review for Resident 1 was initiated on 7/22/25. Resident was admitted to the facility on [DATE], and was discharged on 7/14/25. Review of Resident 1's H&P examination dated 7/9/25, showed the resident had the capacity to understand and make decisions. Review of Resident 1's System Note dated 7/11/25 at 1336 hours, showed the resident had a change in condition wherein resident complained of nausea. Review of Resident 1's Weights and Vitals Summary showed Resident 1's weights for the following dates:dated 7/9/25, the resident weighed 197 pounds;- dated 7/12/25, the resident weighed 180 pounds; anddated 7/13/25, the resident weighed 180 pounds. Further review of Resident 1's plan of care failed to show a care plan problem to address the resident had nausea and weight loss. On 7/23/25 at 0953 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 1's Weights and Vitals Summary showed a weight loss of 17 pounds in four days. LVN 1 verified Resident 1's plan of care was not initiated for the resident's poor appetite and weight loss. On 7/23/25 at 1026 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified a care plan was not initiated for Resident 1's nausea and weight loss. On 7/24/25 at 0954 hours, an interview and concurrent record review was conducted with the RD. The RD stated resident was at risk for weight loss. The RD verified there was no plan of care initiated for the resident to address resident's poor intake and weight loss. The RD further stated she did not initiate a care plan problem until MDS was completed. Event ID: Facility ID: 555141 If continuation sheet Page 3 of 6 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 07/24/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. The facility failed to to notify Resident 1's physician regarding the discharge instructions from the acute care hospital to provide specific fluid amount and type to the resident, and to monitor the resident's intake and output. In addition, the facility failed to notify the physician regarding the resident's weight loss of 17 pounds timely. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being.Findings: a. Review of the facility's P&P titled admission of a Resident revised on 8/23/23, showed the admission process is intended to obtain all the possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. The information gathered will be placed into the resident's medical record via the facility's means of recordkeeping. Review of the facility's P&P titled admission Orders revised on 8/13/23, showed a physician's order is necessary for an individual to be admitted to a facility. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. The written and/or verbal orders should include at a minimum: a. Dietary; b. Medication orders if indicated; and c. Routine care orders. The orders should allow facility staff to provide essential care to the residents consistent with the resident's mental and physical status on admission. The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Closed medical record review for Resident 1 was initiated on 7/22/25. Resident 1 was admitted to the facility on [DATE], and discharged on 7/14/25. Review of Resident 1's After Visit Summary discharge instructions dated 6/24 to 7/8/25, showed to provide the resident at least two liters of fluid (one liter should be water and the other one liter should be an electrolyte solution), and to record how much fluid the resident was drinking and the resident's output from the ostomy everyday. Review of Resident 1's Order Summary Report showed a physician's order dated 7/8/25, to monitor the ileostomy output every shift. However, there was no physician's order to monitor the resident's intake. Further review of Resident 1's medical record failed to show if the Attending Physician was notified regarding Resident 1's discharge instructions from the acute care hospital to monitor the resident's intake and output and provide at least two liters of fluid (one liter should be water and the other one liter should be an electrolyte solution). Review of Resident 1's H&P examination dated 7/9/25, showed the resident had the capacity to understand and make decisions. Review of Resident 1's progress notes dated 7/9/25 at 1050 hours, showed Family Member 1 complained to LVN 2 that the facility was not monitoring the resident's intake and output per the acute care hospital's discharge instructions. On 7/22/25 at 1215 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated the facility refused to monitor the resident's intake and output and provide the fluids as directed in the resident's acute care hospital discharge instructions. Family Member 1 further stated the nurse staff had told her the facility knew how to assess the resident's bowel movement without having to monitor the intake and output. b. Review facility's P&P titled Weight Variance Monitoring revised on 11/17/23, showed unusual or significant weight variance includes the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 4 of 6 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 07/24/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following: a. 3% +/- in one week; b. 5% in 30 days; c. 7.5% in 90 days; and d. 10% in 180 days. Unusual or significant weight losses or gains will be reported by nursing to the physician. When weight loss or gain has been identified as a problem, an entry will be included in the Resident Care Plan and reported to the Providers. Review facility's P&P titled Resident Change of Condition revised on 5/22/24, showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. Routine medical change are all symptoms, and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life-threatening and weight loss or gain. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a change in a resident's condition is noted. If unable to reach a physician, all call to physicians or exchanges requesting callbacks will be documented on the Nursing Progress Note. If the physician has not returned the call by the end of the shift, the on-coming nurse will be notified for follow-up. If unable to contact attending physician or alternate timely, notify the Medical Director for response and follow-up to change in resident status. Document resident change of condition and response in Nursing Progress Notes, on Twenty-Four Hour Report and update resident care plan as indicated. All attempts to reach the physician and responsible party will be documented in the Nursing Progress Notes. Documentation will include time and response. Review of Resident 1's Weights and Vitals Summary showed the following weight for Resident 1: - on 7/9/25, Resident 1 weighed 197 pounds;- on 7/12/25, Resident 1 weighed 180 pounds; and - on 7/13/25, Resident 1 weighed 180 pounds. Review of Resident 1's SNF Documentation Survey Report for nutrition (amount eaten) showed the following:- on 7/8/25, for dinner the resident consumed 0-25% of the meal;- on 7/9/25, for breakfast, lunch, and dinner, the resident consumed 0-25% of the meal and resident refused the supplements offered when the resident ate less than 50% for all the meals; - on 7/10/25, for breakfast the resident consumed 26-50% of the meal and for lunch and dinner, the resident consumed 0-25% of the meal. In addition, the resident refused the supplements offered when the resident ate less than 50% for all the meals; - on 7/11/25, for breakfast and dinner the resident consumed 26-50% of the meal and refused lunch. In addition, the resident refused the supplements offered when the resident ate less than 50% for breakfast and lunch but for dinner, the documentation if the supplement was offered showed NA;- on 7/12/25, for breakfast the resident consumed 26-50% of the meal and 0-25% for dinner, but refused lunch; and- on 7/13/25, for lunch and dinner the resident consumed 0-25% of the meal and refused the supplements offered when the resident ate less than 50% for all the meals. Review of Resident 1's SNF Documentation Survey Report for the bedtime snack showed the following:- on 7/9, 7/11, and 7/13/25, the documentation showed NA; andon7/14 and 7/15/25, the resident refused the snack provided. Review of Resident 1's plan of care failed to show a care plan problem addressing the resident's poor meal intake and weight loss of 17 pounds in four days. Further review of Resident 1's closed medical record failed to show the physician was notified regarding the resident's 17 pounds weight loss on 7/12/25 or on 7/13/25, after being reweighed. In addition, there was no documentation to show the physician was notified regarding Resident 1's poor meal intake. On 7/23/25 at 0953 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 verified Resident 1's After Visit Summary discharge instructions dated 6/24/25 to 7/8/25, showed in the ostomy care section to drink at least two liters of fluid per day to prevent dehydration (one liter should be water, and the other one liter should be an electrolyte solution) and to record how much fluid the resident was drinking and the resident's output from the ostomy everyday. LVN 1 verified the physician was not notified of the resident's discharge instructions. LVN 1 verified Resident 1's Weights and Vitals Summary showed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555141 If continuation sheet Page 5 of 6 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 07/24/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete weight loss of 17 pounds in four days from 7/9 to 7/12/25. LVN 1 verified the resident's medical record failed to show the resident's physician was notified of the weight loss and/or the resident's poor meal intake. LVN 1 stated the physician should have been notified of the resident's significant weight loss. LVN 1 verified Resident 1's plan of care was not initiated to address the resident's poor appetite and weight loss. On 7/23/25 at 1026 hours, an interview was conducted with the DON. The DON verified Resident 1's discharge instructions from the acute care hospital were not relayed to the Attending Physician. The DON stated the physician's orders for the discharge instructions should have been ordered in the facility for the resident's continuity of care. The DON further stated there was too much discharge paperwork, and the licensed nurse usually focused on the resident's discharge medication list to prevent a medication error. The DON further stated the licensed nurse should have notified the physician regarding the resident's significant weight loss prior to the end of shift when the resident was weighed on 7/12/25, and/or reweighed on 7/13/25. On 7/23/25 at 1205 hours, an interview was conducted with the Attending Physician. The Attending Physician stated she usually followed the acute care hospital's discharge instruction per the facility's protocol. The Attending Physician stated she was not aware of the resident's discharge instructions regarding the fluid intake. The Attending Physician stated she could have given an order to provide one liter of fluid from an electrolyte source and one liter from water. The Attending Physician further stated she told the licensed nurse to monitor the resident's intake and output as per the facility's protocol. The Attending Physician stated she was not informed of the resident's weight loss. On 7/24/25 at 1630 hours, a follow up interview was conducted with the DON. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555141 If continuation sheet Page 6 of 6