Health inspection·September 7, 2022

F 0641 Ensure each resident receives an accurate assessment. 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 the MDS assessment was accurate for one of 19 final sampled residents (Resident 9). Residents Affected - Few * The facility failed to ensure the MDS assessment for falls was coded correctly for Resident 9. This created the risk of Resident 9 not receiving an individualized plan of care based on their needs. Findings: Medical record review for Resident 9 was initiated on 8/31/22. Resident was admitted to the facility on [DATE]. Review of the Resident 9's quarterly MDS dated [DATE], showed under Section J1900 (number of falls since admission/entry or reentry or prior assessment), one was coded for Subsection B showing the resident had one fall with injury. Review of Resident 9's Skin Observation Tool assessment dated [DATE], showed Resident 9 had no changes in skin integrity. Review of Resident 9's SBAR assessment dated [DATE], showed Resident 9 had a fall with no changes in skin integrity and no complaints of pain. Review of Resident 9's Weekly Nursing Summary assessment dated [DATE], showed Resident 9 had no changes in skin integrity and no complaints of pain. On 9/7/22 at 1019 hours, a concurrent interview and medical record review was conducted with the MDS nurse. The MDS nurse verified Resident 9 had a fall on 12/18/21. The MDS nurse verified Resident 9 was coded for one fall with injury (except major) under Section J1900, Subsection B. The MDS acknowledged Resident 9's assessments did not reflect the resident's status. The MDS nurse stated Resident 9's MDS Section J1900 should have been coded as no injury under Subsection A. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 2 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 8 was initiated on 8/30/22. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. On 8/30/22 at 0939 hours, Resident 8 was observed in bed, positioned on her back with the HOB elevated at approximately 45-degrees. Resident 8 was lying on a LAL mattress which was on and set between soft and firm. Review of Resident 8's plan of care showed a care plan problem initiated on 3/8/21, addressing the potential for skin integrity impairment related to fragile skin, dependence with bed mobility, and repositioning. However, the care plan was not revised to reflect Resident 8's use of LAL mattress. On 9/6/22 at 1437 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD verified Resident 8 was using a LAL mattress. The DSD stated the use of the LAL mattress should have been included in Resident 8's plan of care. Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the plans of care for three of 19 final sampled residents (Residents 8, 13, and 28) were revised to address the residents' specific care needs. * The facility failed to ensure Residents 13 and 28's care plans were revised to address the use of insulin (a hormone that regulates the amount of glucose in the blood) for diabetes. * The facility failed to ensure Resident 8's care plan was revised to address the use of LAL mattress. These posed the risks for the residents to not receive the care and services required to attain or maintain their highest level of physical and mental well-being. Findings: Review of facility's P&P titled Care Plans, Comprehensive Person-Centered revised date 12/2016 showed the assessments of the residents are ongoing and care plans are revised as information abut the residents and the residents' conditions change. 1. Medical record review for Resident 13 was initiated on 9/1/22. Resident 13 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 8/1/22, showed a physician's order dated 2/18/22, to check the blood sugar before meals on the following scheduled days and times: - Monday at 0630 hours, before breakfast; - Tuesday at 1115 hours, before lunch; - Wednesday at 1615 hours, before dinner; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 3 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 0657 - Thursday at 2100 hours, at bedtime; and Level of Harm - Minimal harm or potential for actual harm - Friday at 1900 hours, after dinner. Residents Affected - Few The physician's order dated 5/15/20, showed to administer Humalog insulin as per sliding scale coverage according to the accu-check results. Review of Resident 13's plan of care showed a care plan problem dated 11/1/20, addressing Resident 13's risk of complications for high or low blood sugar. However, Resident 13's care plan did not reflect the physician's order for the use of insulin medication. 2. Medical record review for Resident 28 was initiated on 9/1/22. Resident 28 was readmitted to the facility on [DATE]. Review of the Order Summary Report dated 8/1/22, showed a physician's order dated 2/18/22, to check the blood sugar before meals on the following scheduled days and time: - Monday at 0630 hours, before breakfast; - Tuesday at 1115 hours, before lunch; - Wednesday at 1615 hours, before dinner; - Thursday at 2100 hours, at bedtime; and - Friday at 1900 hours, after dinner. The physician's order dated 5/27/20, showed to administer Humalog insulin as per sliding scale coverage according to the accu-check results. Review of Resident 28's plan of care showed a care plan problem dated 7/11/22, addressing Resident 28's risk of complications for high or low blood sugar. However, Resident 28's care plan did not reflect the physician's order for the use of insulin medication. On 9/1/22 at 1009 hours, an interview and concurrent medical record review for Residents 13 and 28 was conducted with LVN 3. LVN 3 verified Residents 13 and 28's use of insulin as per a sliding scale coverage for the finger stick blood sugar check. LVN 3 was asked about the care plan problem addressing the use of insulin for Residents 13 and 28, LVN 3 verified there was no information in the care plan reflecting the use of insulin medication. LVN 3 stated the use of insulin medication should have been included in the resients' care plans. On 9/1/22 at 1514 hours, an interview and concurrent medical record review for Residents 13 and 28 was conducted with the DON. The DON was informed of the above findings and verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 4 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 for one of 19 final sampled resident (Resident 28) to help attain and maintain their highest practicable physical well-being. Residents Affected - Few * The facility failed to ensure the process of identifying, communicating, and caring for Resident 28's change of condition was formulated when Resident 28 had an episode of changes in behavior requiring a transfer to another facility for evaluation and treatment. This failure had the potential to affect Resident 28's well-being. Findings: Review of the facility's P&P titled Change in Resident's Condition or Status dated 05/2017 showed the nurse will make detailed observations and gather relevant and pertinent information for the provider, including the information prompted by the facility's communication form. Medical record review was initiated for Resident 28 on 8/31/22. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's Discharge summary dated [DATE], and progress note dated 8/1/22, showed Resident 28 was transferred to the CSU (Crisis Stabilization Unit for mental and behavioral emergency). However, further review of the medical record failed to show the detailed information of Resident 28's change in condition. There was no documented evidence of the facility's communication form formulated and Resident 28 needed to be transferred to another facility. On 9/1/22 at 0853 hours, an interview and concurrent medical record review for Resident 28 was conducted with LVN 3. LVN 3 verified Resident 28 was transferred to another facility when the resident had a change in behavior. LVN 3 was asked what the facility's process was when the residents had a change of condition. LVN 3 stated they monitored the residents, documented the information in the progress notes, and generated a change of condition communication form. LVN 3 was asked the documentation for Resident 28's change of condition. LVN 3 reviewed the medical records and verified there was no communication form generated. LVN 3 stated the change of condition should have been done when the resident was transferred to another facility. On 9/1/22 at 1517 hours, an interview and concurrent medical record review for Resident 28 was conducted with the DON. The DON stated when the residents had a change of condition, a documentation was generated for communication with other staff, the physicians and responsible party of the residents. The DON was informed and verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 5 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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** Based on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 57) was free from unnecessary psychotropic (any drug that affects brain activity) medication. * The facility failed to ensure monitoring of the specific behavior manifestation related to Resident 57's use of Risperdal (antipsychotic medication). This had the potential for inaccurate behavior monitoring and Resident 57's physician not having the necessary information to determine the effectiveness of the medication. Findings: On 8/30/22 at 0854 hours, Resident 57 was observed seating in the wheelchair and speaking in English and another foreign language alternately. Medical record review for Resident 57 was initiated on 8/30/22. Resident 57 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 57 was severely cognitively impaired. Review of Resident 57's Order Summary Report showed a physician's order dated 5/4/22, to administer one tablet of Risperdal (antipsychotic medication) 1.5 mg for schizophrenia manifested by inability to process internal stimuli causing stress or anger. Review of Resident 57's Medication Administration Records for August to September 2022 showed Resident 57 was administered Risperdal 1.5 mg at bedtime as ordered by the physician. The records showed the monitoring for episodes of inability to process internal stimuli causing stress or anger. However, further review of the medical record failed to show documentation of the specific behavior manifestation to justify Resident 57's use of Risperdal. On 9/2/22 at 1123 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 57 could speak English and another foreign language alternately. CNA 2 also stated Resident 57 could verbalize when something bothers her. On 9/7/22 at 0939 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 57 had an active physician's order for Risperdal 1.5 mg to be administered at bedtime for schizophrenia manifested by inability to process internal stimuli causing stress or anger. When asked how the licensed nurses monitored inability to process internal stimuli causing stress or anger, LVN 1 answered when Resident 57 got agitated and started speaking in a foreign language (Resident 57's native language). LVN 1 then verified Resident 57 could speak English and foreign language alternately. LVN 1 also stated Resident 57 would start speaking in English then her foreign language really loudly, trying to get out of chair, and also striking at the staff. LVN 1 stated the behavior manifestation for the use of Risperdal should have been more specific to address Resident 57's inability to process internal stimuli causing stress or anger. LVN 1 stated the behavior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 6 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 manifestation for Risperdal 1.5 mg should be clarified with the physician. Level of Harm - Minimal harm or potential for actual harm On 9/7/22 at 1022 hours, an interview and concurrent medical record review was conducted with LVN 2. When asked how the licensed nurses monitored the resdient's inability to process internal stimuli causing stress or anger for the use of Risperdal, LVN 2 stated they monitored Resident 57 when she got upset for no reason and it depended on what Resident 57 heard due to auditory hallucinations. LVN 2 verified there was no documentation of Resident 57 having auditory hallucinations. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 7 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure puree food was prepared by the method to conserve nutritive value for 19 of 92 residents received pureed foods. This failure placed residents receiving a pureed diet at risk for nutritional impairment. Residents Affected - Few Findings: Review of the facility's P&P titled Food Preparation dated 2018 showed to prepare food as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking. The nutritional value of pureed foods, in particular pureed vegetable, which are heated multiple times compromises both the palatability and nutritional value of foods (www.nutrition.gov). Review of the facility's form titled Diet Type Report dated 9/7/22, showed 19 residents received pureed diet in the facility. On 8/30/22 at 0755 hours, during the initial tour of the facility, an interview was conducted with the CDM regarding the preparation time for the pureed food. The CDM stated the pureed food was prepared at 1000 hours. On 9/1/22 at 0905 hours, an observation of the puree meal preparation for 24 servings was conducted with Cooks 1 and 2. [NAME] 1 pureed green beans for lunch, transferred the pureed green beans into a pan, covered the pan with foil, and placed the pan inside the oven. [NAME] 1 then proceeded in pureeing Salisbury steak, transferred the pureed Salisbury steak into a pan, covered the pan with foil, and placed the pan inside the oven. [NAME] 1 stated the pureed foods were kept in the oven until it was time for the food to be dished out in preparation for the residents' lunch. When asked what time pureed foods were prepared on daily basis for lunch, [NAME] 1 stated the preparation of pureed food was done at 0900 hours, for lunch. On 9/7/22 at 0825 hours, an interview was conducted with the CDM. When asked if she had observed the puree food preparation in the kitchen, she stated she had not. The CDM stated if the pureed food was prepared at 0900 hours, placed in the oven, dished out at 1145 hours, and the meal trays left the kitchen at around 1200 hours. The CDM verified the pureed food stayed in the oven for about two hours and 45 minutes prior to being dished out to be served to the residents. The CDM acknowledged preparing the puree food at 0900 hours was not as close as possible to the serving time. The CDM stated she was not aware of the Cooks pureeing the food at 0900 hours, and the Cooks should have pureed the food at around 1000 to 1030 hours. When asked what could potentially happen if the food was pureed way ahead of time and left in the oven for a long time, the CDM stated the food was losing its nutritional value. On 9/7/22 at 0913 hours, an interview was conducted with the RDN. When asked how soon the puree food should be prepared prior to meal time, the RDN stated the best practice would have been 30 minutes prior to the start of tray line. When asked what could potentially happen when the pureed food was left in the oven for hours, the RDN stated the food dries out, the quality would be compromised and may cause decrease food intake for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 8 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 as evidenced by the following: Residents Affected - Some * The facility failed to ensure the food items were labeled accurately and the breads were properly stored. * The facility failed to ensure the kitchen equipment and clean areas were maintained in sanitary condition. * The facility failed to ensure the cutting board was in sanitary condition and with cleanable surface. * The facility failed to ensure food preparation in a sanitary condition. * The facility failed to ensure the freezer temperature were checked and logged on a regular basis. 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 titled Resident Census and Conditions of Residents completed by the facility dated 8/30/22, showed 85 of 91 residents in the facility received food prepared in the kitchen. Review of the facility's P&P titled Storage of Food and Supplies dated 2017 showed the following: a. Food and supplies will be stored properly and in a safe manner. b. All food products will be dated - month, day, and year. All food products will be used per the times specified in the Dry Food Storage Guidelines. c. Do not store bread in the refrigerator. Review of the facility's P&P titled Sanitation dated 2018 showed the following: a. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. b. Plastic ware, china and glassware that become unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded. Review of the facility's P&P titled Procedure for Freezer Storage dated 2018 showed the freezer temperatures should be recorded twice daily. Temperatures are to be recorded upon opening and closing of kitchen by a designated employee and logged in the Cold Storage Temperature Log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 9 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. According to the FDA Food Code 2017, Section 3-501.17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: Marking, the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. On 8/30/22 at 0755 hours, an initial tour of the kitchen was conducted with the CDM. During the initial tour, the following was observed: a. Inside the walk-in refrigerator: - Seven bars of 16 oz. Imperial European Style Margarine Butter Blend with no received date and best by date. - Two peach colored trays containing clear dessert bowls with pureed peaches, covered with plastic wraps, labeled with the date of 8/3/22. - Several bags of Hoagie sliced bread and whole wheat sandwich bread. b. Inside the Dry Storage Room: - Three boxes of Ready Care Thickened Water 48/4 fluid oz. labeled with the received date of 9/19/22. - Five bags of Buttermilk Biscuit Mix with the received date of 8/3/22. There was no best by date observed on the bags. - Two bottles of Sysco Barbecue Sauce sealed with the received date of 8/10. There was no best by date observed on the bottles. - One bottle of Corn Oil, sealed with the received date of 8/26/22. There was no best by date observed on the bottle. c. Inside the walk-in freezer: - One box of Turkey Patties with the best by date of 8/3/22. - One box of Veal Parmigiana with the best by date of 8/3/22. - Two boxes of Country Fried Steak Fritters with the best by date of 8/3/22. During the initial tour, the CDM acknowledged and verified all the findings identified. On 9/7/22 at 0825 hours, a follow-up interview was conducted with the CDM regarding the findings. The CDM stated the following: - The best by date of 8/3/22, on the frozen Turkey Patties, Veal Parmigiana, and Country Fried Steak Fritters was an error on the label gun and should have been labeled with the received of 8/3/22, and not the best by date. - The pureed peaches inside the walk-in refrigerator dated 8/3/22, was a label gun issue and should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 10 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 have been labeled with the date of 8/30/22. Level of Harm - Minimal harm or potential for actual harm - The seven bars of butter on a tray inside the walk-in refrigerator, without received date and best by date usually had a label on the tray. The tray may have been moved and the label probably got lost. Residents Affected - Some - The breads were kept in the walk-in refrigerator because of space issue and the kitchen did not have a place to store the breads. When asked when happens to the bread when stored in the refrigerator, the CDM stated the bread would loss moisture and stale. - The five bags Buttermilk Biscuit Mix did not have a best by date because she missed labeling the bags. - The Ready Care Thickened water, three boxes of 48/4 fluid oz. with the received date of 9/19/22, was an error on the labeling gun and was corrected to show 8/19/22, as the received date. - The barbecue sauce and corn oil should have had a best by date on the bottles. 2. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food, residue, and other debris. According to the FDA Food Code Annex 4-602.13, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. a. On 8/30/22 at 0755 hours, an initial tour of the kitchen was conducted with the CDM. During the initial tour, the following was observed: - A can opener with rust on the blade and showed signs of worn out blade. - Two black and one gray plastic bins used to soak silverwares had white, dried residue on the outer side of the bins, and worn out appearance. - The clean drying area to place the clean dishes was observed with food residue on the counter. The counter had a dish rack drying clean trays when the food residue was observed on the counter. During the initial tour, the CDM acknowledged and verified the findings identified. On 8/30/22, an interview and concurrent observation was conducted with Dietary Aide 2. Dietary Aide 2 verified the presence of food residue on the clean drying area of the dishes. Dietary Aide 2 stated he did not know how the food residue ended up on the clean drying area, and the area needed to be cleaned. On 9/7/22 at 0825 hours, a follow-up interview was conducted with the CDM regarding the findings. The CDM stated the following: - The can opener was rusty and the blade was peeling off. The blade was changed every two months (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 11 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and was due to have it changed. The can opener was ordered in August 2022 and would take 10 weeks to process. On 9/7/22 at 0913 hours, an interview was conducted with the RDN. The RDN was asked if the can opener blade had contact with food when used. The RDN stated yes. When asked if the can opener with peeling surface on the blade should be used, the RDN stated it should not be used because of possible food contamination. 3. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free of sharp internal angles, comers, and crevices, and finished to have smooth welds and joints. On 8/30/22 at 0755 hours, an initial tour of the kitchen was conducted with the CDM. During the initial tour, a green cutting board was observed with deep groves and heavily marred. The CDM verified the findings and stated the cutting board will be thrown out and replaced. 4. On 9/1/22 at 0905 hours, an observation of the puree meal preparation was conducted with Cooks 1 and 2. During the observation, [NAME] 2 obtained the following disher/serving spoons from a container on the counter of the food preparation area: - One 4 oz/l l 8 ml perforated spoodle with black handle - One size 8 disher, ½ cup/4 oz with gray handle - One size 12 disher, 1/3 cup/3 and ¼ oz Cook 2 placed the perforated spoodle and two dishers directly on the metal counter where the puree meal was being prepared. Next to the spoodle and dishers was the recipe hinder which was placed directly on the counter. Cook 2 handed the perforated spoodle to [NAME] I to dish out the green beans from the pan to the blender. [NAME] 1 placed the perforated spoodle directly on the counter of the food preparation area after being used. [NAME] 2 then handed the size 8 disher to [NAME] 1. [NAME] 1 used the size 8 disher to scoop thickener from the bin located under the food preparation area. [NAME] 1 placed the size 8 disher directly on the counter after scooping the thickener from the bin. [NAME] 1 pureed the green beans, transferred into a pan, covered with foil, then put it in the oven. On 9/1/22 at 0910 hours, [NAME] 1 proceeded to prepare puree Salisbury steak. [NAME] 1 placed the meat in the blender, used the same size 8 disher to scoop the thickener from the bin located under the food preparation area. [NAME] 1 placed the size 8 disher directly on the counter after use. The Salisbury steak was pureed, transferred into a pan, covered with foil, and then placed inside the oven. On 9/1/22 at 0930 hours, an interview was conducted with [NAME] 1. When asked if the pureed green beans and Salisbury steak were to be served to the residents for lunch, [NAME] 1 stated yes. The CDM who was present during the puree meal preparation was asked if the pureed green beans and Salisbury steak were to be served to the residents for lunch. The CDM stated it would not be served because the food was contaminated already because the scoops should have been placed on a plate, not directly on the counter. The CDM further stated the [NAME] would need to prepare a new puree food for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 12 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 residents and the thickener from the bin needed to be disposed. Level of Harm - Minimal harm or potential for actual harm 5. On 8/31/22 at 0850 hours, an observation and concurrent interview was conducted with the CDM. Freezer 2 located in the employee patio was observed with the temperature log. The Daily Freezer Temperature Log from 8/1 -8/31/22, showed the temperature was to be monitored daily. However, the log had missing temperature entries for 8/5, 8/6, 8/11, 8/12, 8/17, 8/18, 8/23, 8/24, 8/29, and 8/30/22. The CDM stated there was a staff who checked the freezer daily, and the missing temperatures correlated with the days when the staff was off. The CDM verified Freezer 2 should be checked daily. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 13 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 and interview, the facility failed to ensure the garbage was disposed of properly and covered at all times. One of the three garbage dumpsters was missing a cover. This had the potential to harbor pests. Residents Affected - Some Findings: On 8/31/22 at 0850 hours, an observation and concurrent interview was conducted with the CDM. There were three dumpsters located outside of the kitchen by the side entrance towards the TRC side of the facility. One of the three dumpsters had a missing lid and contained trash inside. Flies were observed flying over and around the partially covered dumpster. The CDM verified the findings and stated the dumpster should not have been used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 14 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 interview and medical record review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 52) was accurately maintained. Resident 52 had an advance directive, but the resident's POLST did not show the resident had the advance directive. This failure put the resident at risk for error in medical care and delay in treatment. Findings: Medical record for Resident 52 was initiated on 8/30/22. Resident 52 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 52's POLST dated 2/19/21, Section D showed there resident had no advance directive and had legally recognized decision maker. On 9/6/22 at 1259 hours, an interview and concurrent medical record review was conducted with the Medical Records Supervisor. The Medical Records Supervisor stated Resident 52 had a legally recognized decision maker and provided with a copy of Advance Health Care Directive dated 11/14/13. On 9/7/22 at 0941 hours, and interview and concurrent medical record review was conducted with the SSD. When asked who filled out the POLST, the SSD stated the nurses filled out the form. The SSD verified the information on the POLST was inaccurate and should have included the advance directive dated 1/14/13. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 15 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 3. Review of the facility's P&P titled Handwashing/Hand Hygiene revised August 2019 showed the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after eating or handling food. Residents Affected - Some On 8/30/22 at 1217 hours, a dining observation was conducted in the main dining room. The CNAs were observed wheeling the residents to the main dining room, one at a time, in preparation for lunch. A bottle of hand sanitizer was observed on the table next to the TV; however, two of 19 final sampled residents (Residents 3 and 7) and three nonsampled residents (Residents 17, 31, and 54) were not provided with hand hygiene prior to being served lunch in the main dining room. On 8/31/22 at 1410 hours, an interview was conducted with CNA 6. CNA 6 was observed feeding Resident 7 during lunch on 8/30/22, without providing hand hygiene prior to being fed. When asked regarding the facility's process to prepare the residents for meal times. CNA 6 stated the staff would wait for the main dining room to open; and the licensed nurse would check the residents' trays, put the trays on the table, then feed the residents. When asked what was done prior to feeding the residents, CNA 6 stated the staff placed the clothes protector so the residents would not get dirty. When asked about hand hygiene, CNA 6 stated the staff usually washed the residents' hands before taking them to the dining room, then the residents' hands were cleaned with hand sanitizer. CNA 6 verified she did not provide hand hygiene to Resident 7 before she was fed lunch on 8/30/22, because she just forgot. When asked what could potentially happen if hand hygiene was not provided, CNA 6 stated the residents could put their dirty fingers in their mouths and get sick. On 8/31/22 at 1420 hours, an interview was conducted with CNA 4. CNA 4 was observed feeding Resident 3 during lunch on 8/30/22, without providing hand hygiene prior to being fed. When asked regarding the facility's process to prepare the residents for meal times, CNA 4 stated the staff would usually know which table the residents assigned in the main dining room. The staff would clean the residents' hands with the hand sanitizer wipes or gel. When asked why Resident 3 was not provided hand hygiene prior to being fed lunch, CNA 4 verified she did not provide hand hygiene because Resident 3 was a feeder. CNA 4 stated the staff provided hand hygiene if the residents fed themselves, or if the residents were feeders with visibly dirty hands. On 8/31/22 at 1442 hours, an interview was conducted with the DSD. The DSD stated the staff only provided hand hygiene to the residents when their hands soiled. Any residents who not needing to handle food did not require hand hygiene. If the residents were able to handle food supplies or food during dining time, then they should have been provided with hand hygiene. On 8/31/22 at 1556 hours, a follow-up interview was conducted with the DSD regarding the facility's P&P for Handwashing/Hand Hygiene revised 8/2019. The DSD acknowledged the findings. Based on observation, interview, record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the transmission of diseases and infections. * The facility failed to ensure the staff practiced enhanced barrier precautions when entering the rooms of one of 19 sampled residents (Resident 56) and one nonsampled resident (Resident 4) who were on enhanced barrier precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 16 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 facility failed to ensure the infection control practices were maintained in the facility's laundry room area. Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure the staff offered hand hygiene to the residents prior to meals. Residents Affected - Some These failures posed the risk of infection and the transmission of disease-causing microorganisms. Findings: 1. According to the CDC, enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve 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 of MDRO acquisition. Review of the facility's sign for Enhanced Barrier Precautions showed everyone must clean their hands, including before entering and when leaving the room. It also showed providers and staff must wear gloves and gown for the following high-contact resident care activities: dressing, bathing/ showering, transferring, changing linens providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. a. On 8/30/22 at 0839 hours, Resident 4's room was observed with an enhanced barrier precaution sign posted by the door. CNA 1 was observed bringing in Resident 4 into the room and dressing Resident 4. CNA 1 was only wearing the gloves and mask but did not wear a gown. * On 8/31/00 at 1438 hours, an interview was conducted with CNA 1. CNA 1 verified the above findings. CNA 1 stated she showered Resident 4 yesterday, then dressed her. CNA 1 also stated she changed the resident's bed linens. CNA 1 verified there was a sign by the wall showing Resident 4 was on enhanced barrier precaution. CNA 1 stated she missed the sign and should have worn the mask, gloves, and gown. * On 9/1/22 at 0920 hours, CNA 2 was observed assisting Resident 4 in the bathroom. CNA 2 was observed wearing mask, faceshield, and gloves but did not wear a gown. On 9/1/22 at 0926 hours, an interview was conducted with CNA 2. CNA 2 verified the above findings. CNA 2 stated he assisted Resident 4 in the bathroom and changed the resident's incontinence briefs and bed linens. CNA 2 verified there was a sign by the wall showing Resident 4 was on enhanced barrier precaution. CNA 2 stated he missed the sign and should have worn the mask, gloves, and gown. b. On 8/30/22 at 0818 hours, Resident 56's room was observed with an enhanced barrier precaution sign posted by the door. CNA 3 was observed inside the room. CNA 3 was observed wearing the mask and gloves but was not wearing a gown. On 8/30/22 at 0820 hours, CNA 1 went inside the room. CNA 1 was observed wearing the mask and gloves but was not wearing a gown. On 8/30/22 at 0830 hours, CNA 3 was observed changing the resident's bed linens. On 8/30/22 at 0843 hours, CNA 3 was observed bringing Resident 56 into the room, and asked CNA 4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 17 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for help. CNA 4 was observed going into the room. Both CNAs were observed wearing the masks and gloves but not wearing gowns. On 8/30/22 at 0955 hours, an interview was conducted with CNA 3. CNA 3 verified the above findings. CNA 3 stated CNA 1 helped her transfer Resident 56 from the bed to gerichair. CNA 3 stated she changed the resident's bed linens, then showered Resident 56 in the shower room. CNA 3 also stated CNA 4 helped her transfer Resident 56 from the gerichair to bed, then CNA 3 dressed the resident. CNA 3 acknowledged they wore the masks and gloves but did not wear gowns while providing the resident care. CNA 3 verified there was a sign by the wall showing Resident 56 was on enhanced barrier precaution. CNA 3 the enhanced barrier precaution was for the other resident but was not sure if the isolation was already discontinued. On 9/1/22 at 1415 hours, an interview, and concurrent medical record review was conducted with the IP. The IP verified the above findings. The IP verified Residents 4 and 56 were on enhanced barrier precautions. The IP stated when the residents were on enhanced barrier precautions, the staff were expected to wear the mask, gloves, and gown when providing direct and closed contact care such as transferring, incontinence brief change, showering, dressing, and changing linens. 2. Review of the facility's P&P titled Employee Lockers/ Storage Space revised January 2008 showed the employees may not store personal belongings in unauthorized spaces within the facility to include the resident rooms and common areas. On 8/31/2022 at 0845 hours, an observation and concurrent interview was conducted with the Laundry Supervisor. The following was observed: - A plastic bag containing bread was observed on top of the folded socks on the folding table in the clean area. - A radio was observed on the upper shelf of a clean linen cart. The radio was touching folded resident gowns. - A bag was observed on the bottom shelf of a clean linen cart. The bag was touching the resident's clothes. The Laundry Supervisor verified the findings. The Laundry Supervisor stated any personal items should not have been stored in the clean laundry area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 18 of 19 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to ensure a sanitary and comfortable environment was maintained. The employee refrigerator was not maintained in sanitary and good repair conditions. This placed the staff at risk of not being provided a comfortable and sanitary environment. Findings: On 8/31/22 at 0850 hours, an observation and concurrent interview was conducted with the CDM. The employees' refrigerator was observed in the employee patio. The lower refrigerator door had an orange-brownish residue on top of the lower door. The refrigerator had the unlabeled and undated food items. The CDM verified the findings. On 9/7/22 at 0825 hours, a follow-up interview was conducted with the CDM. When asked who monitored the refrigerator in the employee patio, the CDM stated she was not sure. When the CDM was asked if she checked the employee refrigerator, she stated she opened it to check what was in it, and also checked for anything that looked bad and should not be in there. When asked if the food in the employees' refrigerator must be dated, the CDM stated she did not know the policy. The CDM verified the employees' refrigerator was old and there was rust on the top and front of the lower door. The CDM also stated the refrigerator should be painted or replaced. On 9/7/22 at 0913 hours, an interview was conducted with the RDN. When asked, the RDN stated the refrigerator needed to be cleaned, and the items inside the refrigerator needed to label and date. When asked if the temperature should be monitored, the RDN stated yes, ideally, but she did know if it was required, but the practice was to monitor. On 9/7/22 at 1013 hours, and interview was conducted with the Administrator. The Administrator stated the facility did not have a policy regarding refrigerator use for the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555211 If continuation sheet Page 19 of 19