Health inspection·June 16, 2025

F 0605 On 06/13/25 at 1630 hours, the DON was informed of and acknowledged the above findings. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 42) and one nonsampled resident (Resident 1) reviewed for unnecessary medications were provided with the non-pharmacological interventions for the use of psychotropic medications+. Residents Affected - Few * The facility failed to ensure Resident 42 was provided with non-pharmacological interventions for the use of Remeron (antidepressant) medication. * The facility failed to ensure Resident 1 was provided with non-pharmacological interventions for the use of Abilify (antipsychotic) medication. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medications revised 1/30/25, showed it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. The Policy Explanation and Compliance Guidelines section showed the non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication. Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 1/30/25, showed the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: - The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 1. On 6/10/25 at 0854 hours, Resident 42 was observed sitting in a wheelchair and just came back from physical therapy. Resident 42 stated she felt better and ready to go home. Medical record review for Resident 42 was initiated on 6/10/25. Resident 42 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 42's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired. Review of Resident 42's Psychiatric Evaluation Note dated 5/21/25, showed the resident was diagnosed with MDD. Review of Resident 42's Order Summary Report dated 6/13/25, showed a physician's order dated 4/30/25, for Remeron oral tablet 15 mg (mirtazapine), give one tablet by mouth at bedtime for depression manifested by episodes of verbalization of sadness. Further medical record review for Resident 42 failed to show documented evidence the non-pharmacological interventions were provided for the use of the Remeron medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 2 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 6/13/25 at 1022 hours, an interview and concurrent medical record review for Resident 42 was conducted with RN 1. RN 1 verified there was no non-pharmacological intervention for Resident 42's use of the Remeron medication. RN 1 further stated the licensed nurse should document the non-pharmacological intervention on the progress notes. On 6/13/25 at 1146 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON acknowledged the above findings. The DON stated Resident 42's psycho-spiritual needs were met. The DON further stated the non-pharmacological interventions for the use of the Remeron medication were provided to Resident 42, however, was not documented. The DON stated the licensed nurse had to assess the resident's behavior and mood before giving the medication and the licensed nurse needed to listen and give emotional support if the resident expressed their feelings. The DON stated the licensed nurse should document the non-pharmacological intervention on the progress note. Event ID: Facility ID: 555266 If continuation sheet Page 3 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to accurately assess the risk for falls for one of four final residents (Resident 30) reviewed for accidents. This failure had the potential to negatively impact Resident 30's well-being. Residents Affected - Some Findings: Review of the facility's P&P titled Fall Prevention Program revised 1/30/25 showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The Policy Explanation and Compliance Guidelines section showed the facility utilizes a standardized risk assessment for determining a resident's fall risk. Review of the facility's P&P titled Fall Risk Assessment revised 1/30/25, showed the risk assessment will be completed by the nurse or designee upon admission, annually, or when a significant change is identified. Review of the facility's P&P titled Documentation in Medical Record revised 1/30/25, showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The Policy Explanation and Compliance Guidelines section showed principles of documentation include, but are not limited to: - Documentation shall be factual, objective, and resident centered. False information shall not be documented. Closed medical record review for Resident 30 was initiated on 6/9/25. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired. Review of Resident 30's eINTERACT Change in Condition Evaluation - V5.1 dated 5/22/25, showed the resident fell on 5/22/25. Review of Resident 30's Fall Risk - V4 assessment dated [DATE], showed the resident had no falls in the past three months. On 6/12/25 at 1404 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified Resident 30 fell on 5/22/25. However, the Fall Risk - V4 assessment showed Resident 30 had no falls in the past three months. RN 1 stated the licensed nurse should have answered one to two falls in the past three months on the history of falls question, so it could be accurate and to provide a better fall prevention. On 6/13/25 at 1140 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON acknowledged the above findings. The DON stated the resident fell and the licensed nurse should have answered one to two falls on the question for the history of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 4 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - 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 observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of five final sampled residents (Resident 22). * The facility failed to develop a care plan to address Resident 22's use of floor mat. This failure had the potential risk of not providing appropriate, consistent, and individualized care to Resident 22. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 1/30/25, showed it is the policy of this 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 comprehensive assessment. On 6/10/25 at 0836 hours, Resident 22 was observed sitting on her wheelchair and looking at the window. One floor mat was observed at the left side of Resident 22's bed. Medical record review for Resident 22 was initiated on 6/10/25. Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 22's MDS assessment dated [DATE], showed Resident 22 had severe cognitive impairment. Review of Resident 22's Fall Risk - V4 assessment dated [DATE], showed the resident was at risk for fall. Further medical record review for Resident 22 failed to show a plan of care for the use of the floor mat. On 6/10/25 at 1232 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified Resident 22 had one floor mat on the left side of the bed. RN 2 further stated Resident 22 had one floor mat because she preferred to move at the left side of the bed. RN 2 stated Resident 22 had floor mat because the resident was at risk for falling. On 6/10/25 at 1239 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified there was no care plan for the use of the floor mat. RN 2 stated the licensed nurse forgot to update Resident 22's care plan for the use of the floor mat. On 6/13/25 at 1135 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings. The DON stated the floor mat was part of the intervention when the resident was high risk for fall. The DON stated the supervisor, MDS nurse, or licensed nurse should have updated the care plan for Resident 22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 5 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Residents 608) reviewed for pain management. Residents Affected - Few * The facility failed to accurately document the monitoring of pain for Resident 608. In addition, the facility failed to ensure the non-pharmacological interventions for Resident 608's pain was consistently documented prior to the administration of the Norco (narcotic pain medication) and failed to document the complete pain assessment for Resident 608's pain prior to the administration of pain medication as per Resident 608's care plan. These failures had the potential to put Resident 608 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Management revised 1/30/25, showed based upon the (pain) evaluation the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. Non-pharmacologic interventions will include but are not limited to: environmental comfort measures, loosening any constrictive bandage, clothing or device, applying splinting, physical modalities, exercise to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility, or cognitive/behavioral interventions. Pharmacologic interventions will follow a systemic approach for selecting medications and doses to treat pain. The facility staff will reassess the resident's pain management regularly for effectiveness and/or adverse consequences. If reassessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If the pain has resolved or there is no longer an indication for pain medication the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion. Medical record review for Resident 608 was initiated on 6/9/25. Resident 608 was admitted to the facility on [DATE]. Review of Resident 608's MDS assessment dated [DATE], showed Resident 608 was cognitively intact. Review of Resident 608's Order Summary Report dated 6/11/25, showed the following physician's orders: - dated 5/20/25, for Resident 608's pain evaluation, every shift, - dated 5/20/25, to administer hydrocodone-acetaminophen (narcotic opioid medication) 5-325 mg one tablet by mouth every four hours as needed for severe pain management (pain levels of 7 to 10, on a 0-10 pain scale with 0 = no pain and 10 = worst pain) for 30 days. Do not exceed three grams of acetaminophen per day for all sources, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 6 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - dated 5/23/25, to administer morphine sulfate Contin (narcotic opioid medication) extended-release 30 mg, one tablet by mouth every 12 hours for pain management due to breast cancer and metastatic malignant mass. Review of Resident 608's plan of care showed a care plan problem dated 5/21/25, addressing Resident 608's pain related to Resident 608's breast cancer with left mastectomy, metastatic malignant mass on Resident 608's left neck and status-post a laminectomy. The interventions included to administer the analgesia Tylenol, Norco, and morphine sulfate Contin 30 mg as per the physician's orders, to monitor/record the pain characteristics and PRN: quality (e.g. sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g. continuous, intermittent); aggravating factors; relieving factors; and to provide the non-pharmacological interventions to alleviate pain (Specify: provide warm blanket when cold, provided cool drink when hot, provide extra snack when hungry, provide quiet environment when tired). a. Review of Resident 608's MAR for 5/2025 showed Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for severe pain (pain levels of 7 to 10) on the following dates, times, and pain levels: - on 5/21/25 at 1420 hours, for a pain level of 10. - on 5/22/25 at 1443 hours, for a pain level of 10. However, review of Resident 608's medical record failed to show the documentation of the non-pharmacological pain interventions attempted prior to the administration of the hydrocodone-acetaminophen pain medications for the above dates and times. On 6/11/25 at 1332 hours, an interview and concurrent medical record review for Resident 608 was conducted with LVN 1. LVN 1 stated Resident 608 complained of pain in her left chest and her back. LVN 1 stated Resident 608 was administered the morphine pain medication routinely and the Norco and the Tylenol pain medications administered as needed. LVN 1 stated when the resident reported pain, the non-pharmacological interventions were implemented and documented in the nurse's progress notes prior to the administration of the pain medications. LVN 1 further stated if the non-pharmacological pain interventions were effective, the pain medication would not need to be administered. LVN 1 reviewed resident 608's medical record and verified the above findings. b. Review of Resident 608's MARs for May and June 2025 showed Resident 608 was administered the following medications on the following dates, times, and pain levels: * Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for severe pain (pain levels of 7 to 10): - on 5/20/25 at 2305 hours, for a pain level of 10. - on 5/21/25 at 0450 hours, for a pain level of 8; at 0915 hours, for a pain level of 7; at 1420 hours, for a pain level of 10; at 1918 hours, for a pain level of 8; and at 2350 hours, for a pain level of 8. - on 5/22/25 at 0445 hours, for a pain level of 7; at 0934 hours, for a pain level of 7; at 1443 hours, for a pain level of 10; and at 2300 hours, for a pain level of 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 7 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 - on 5/23/25 at 0450 hours, for a pain level of 7; at 0900 and 1315 hours, for a pain level of 7. Level of Harm - Minimal harm or potential for actual harm - on 5/24/25 at 0250 hours, for a pain level of 8. - on 5/31/25 at 1000 hours, for a pain level of 7; and at 1518 hours, for a pain level of 7. Residents Affected - Few * Resident 608 was administered the morphine sulfate Contin extended release 30 mg, one tablet by mouth every 12 hours for pain management: - from 5/24 to 5/31/25 at 0900 and 2100 hours, and - from 6/1 to 6/10/25 at 0900 and 2100 hours (except on 6/6/25 at 2100 hours). Review of Resident 608's Monitor Record for May 2025 for the monitoring of Resident 608's pain evaluation every shift, showed the licensed nurses documented Resident 608's pain level as follows for the following dates and shifts (when the hydrocodone-acetaminophen pain medication was administered for severe pain, pain level of 7 to 10): - on 5/20/25 for the 2300 to 0700 hours shift, the pain evaluation was documented as 2, - on 5/21/25, for the 0700 to 1500 hours shift and the 1500 to 2300 hours shift, the pain evaluation was documented as 0; and for the 2300 to 0700 hours shift, the pain evaluation was documented as 1. - on 5/22/25, for the 0700 to 1500 hours shift, the pain evaluation was documented as 0. - on 5/23/25, for the 0700 to 1500 hours shift, the pain evaluation was documented as 1, and for the 2300 to 0700 hours shift, the pain evaluation was documented as 1. - on 5/31/25, for the 0700 to 1500 hours shift and the 1500 to 2300 hours shift, the pain evaluation was documented as 0. Review of Resident 608's medical record failed to show documentation the licensed nurses assessed Resident 608's pain (including the pain location, level, quality, characteristics, and alleviating/aggravating factors) prior to the administration of the morphine sulfate pain medication. On 6/16/25 at 0838 hours, an interview and concurrent medical record review for Resident 608 was conducted with the DON. The DON stated when the resident had reported pain, the licensed nurse should assess the resident's pain, and implement and document the non-pharmacologic pain interventions and its effectiveness in the nursing progress notes. The DON stated if the non-pharmacologic pain interventions for pain were not effective, the licensed nurse would administer the pharmacological pain intervention, per the physician's order, and evaluate its effectiveness. The DON stated the facility was responsible for the monitoring of the resident's pain, which included the tracking and trending of the resident's pain. The DON stated the monitoring of the resident's pain each shift would assist in determining if there was a pattern for the resident's pain, and would also assist in determining when the pain medications would no longer be needed. The DON stated the licensed nurses were responsible for monitoring and documenting the resident's pain level every shift. The DON stated the pain evaluation should be documented at the end of shift, to accurately reflect the resident's highest level of pain during the shift. The DON further stated, if the PRN pain medications were administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 8 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm to the resident during the shift for the pain levels of 5 out of 10 and 8 out of 10, when documenting the monitoring of pain for that shift, the licensed nurse was expected to document the pain level of eight for that shift because that was the resident's highest level of pain. The DON reviewed Resident 608's medical record and verified the above findings. The DON stated for the administration of the routine pain medications, the resident's pain should be assessed and documented in the progress notes. Residents Affected - Few c. Review of Resident 608's Progress Notes, showed the following licensed nurses entry documentation: - dated 5/27/25 at 0043 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/28/25 at 0912 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/29/25 at 1007 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/30/25 at 0933 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/1/25 at 0556 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/2/25 at 1400 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/3/25 at 1101 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/4/25 at 0913 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/5/25 at 0929 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/6/25 at 1039 hours, the licensed nurse documented Resident 608's pain score was 7, nonmedication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/7/25 at 1346 hours, the licensed nurse documented Resident 608's pain score was 7, non-medication interventions did not provided relief, PRN medication provided. See MAR for details. However, review of Resident 608's MARs for May and June 2025 failed to show Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg one tablet every four hours as needed for severe pain, pain level of 7 to 10. On 6/16/25 at 1134 hours, an interview and concurrent medical record review for Resident 608 was conducted with the DON. The DON reviewed Resident 608's medical record and verified the above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 9 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 findings. Level of Harm - Minimal harm or potential for actual harm On 6/16/25 at 1350 hours, the Administrator and the DON were informed and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 10 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/11/25 at 1116 hours, sn observation and concurrent interview was conducted with the DON. When asked about the facility's process for the disposition of controlled substances, the DON showed a drawer used to store the controlled substances to be destroyed with the pharmacist. According to the DON, the pharmacist and DON conducted disposition of the controlled substances on a monthly basis. During the observation of the drawer containing controlled substances for the disposal, one used patch without a pharmacy label was observed stored inside the drawer. The DON stated the patch was a Fentanyl (opioid) patch. When asked about the patch was missing a pharmacy label, the DON stated she knew who the patch was used for. On 6/13/25 at 1050 hours, a follow-up observation and concurrent interview was conducted with the DON. Two used Fentanyl patches without the pharmacy labels were observed inside the drawer used to store controlled substances to be disposed of. When asked about the facility's process for keeping a record for the accurate reconciliation of the Fentanyl patches stored inside the drawer, at all times, the DON verified she did not have the documentation. The DON stated she would obtain the Controlled Drug Record for the Fentanyl from the licensed staff when the pharmacist came to the facility on a monthly basis to do the medication destruction. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure Resident 12's BP was taken in appropriate time when administering the medications for hypertension. * LVN 1 failed to administer Resident 12's docusate sodium (stool softener) as ordered by the physician. * The facility failed to establish a system of records for Fentanyl patches that were already used and ready to be disposed. These failures had the potential to negatively affect the residents' health condition for possible complications. Findings: 1.a. Review of the facility's P&P titled Medication Administration revised 1/30/25, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section showed to compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. On 6/11/25 at 0846 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 prepared and administered the following medications to Resident 12: - one tablet of amlodipine besylate (medication to treat high blood pressure and chest pain) 2.5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 11 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 mg; Level of Harm - Minimal harm or potential for actual harm - one tablet of losartan (medication to treat high blood pressure) 50 mg; - one tablet of docusate sodium (stool softener) 100 mg; Residents Affected - Few - two tablets of acetaminophen (pain reliever) 500 mg; - two tablets of cranberry (supplement) 450 mg; - two capsules of Fish Oil (supplement) 500 mg; and - 60 cc of Boost nutritional drink. Medical record review for Resident 12 was initiated on 6/11/25. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 12's Order Summary Report dated 6/11/25, showed the following physician's orders: - dated 12/23/22, to administer amlodipine besylate tablet 2.5 mg. Give one tablet by mouth in the morning for hypertension; and - dated 1/6/22, to administer losartan potassium tablet 50 mg. Give one tablet by mouth one time a day for hypertension. Review of Resident 12's Weights and Vitals Summary dated 6/12/25, showed the resident's blood pressure of 126/76 mmHg was taken on 6/11/25 at 0652 hours. On 6/11/25 at 0901 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified Resident 12's BP was taken at 0652 hours and she administered the amlodipine besylate and losartan potassium medications at 0846 hours. LVN 1 acknowledged she did not take Resident 12's BP just before giving the medications for hypertension. LVN 1 stated Resident 12 had been taking the hypertension medication for a long time and did not need to have the BP taken. On 6/13/25 at 1130 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have taken Resident 12's BP before giving the medication because the BP could change. b. Review of Resident 12's Order Summary Report dated 6/11/25, showed a physician's order dated 12/2/21, to administer docusate sodium (stool softener) capsule 250 mg. Give one capsule by mouth in the morning for bowel management. Hold if with loose stool. On 6/11/25 at 1139 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified she administered 100 mg tablet instead of 250 mg capsule of docusate sodium to Resident 12. LVN 1 stated she got confused with the dosage when she gave the docusate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 12 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 sodium medication to Resident 12. Level of Harm - Minimal harm or potential for actual harm On 6/13/25 at 1123 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have checked the physician's order and checked the medication before giving to Resident 12. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 13 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure the opened food items in the freezer were properly stored, dated, and labeled. * The facility failed to discard the items in the refrigerator that were past the use-by date, as per the facility's P&P. * The facility failed to ensure the juice boxes and thickener (for the juice dispenser) were properly labeled and discarded. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure the plastic cup was not stored inside the flour container. * The facility failed to air dry the kitchen equipment. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 61 residents who received food prepared in the kitchen. Findings: Review of the facility's document titled Diet Type Report dated 6/9/25, showed 61 of 61 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Review of Sanitation revised 9/26/18, showed all the food stored should be dated when it is placed in the storeroom, refrigerator, or freezer. The food in all the refrigerators should have a use-by-date. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. On 6/9/25 at 0750 hours, an observation of Freezer 1 was conducted with the DSS. The following were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 14 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 observed: Level of Harm - Minimal harm or potential for actual harm - an opened bag of the frozen hashbrowns. The bag was not observed labeled with the opened date or stored inside a sealed bag. Residents Affected - Some - an opened blue bag containing the frozen Danishes. The label showed received on 5/28/25. The label was not observed with the opened dated or stored inside a sealed bag. - an opened bag of the frozen cinnamon rolls. The bag was not observed stored inside a sealed bag and two cinnamon rolls were observed outside of the bag and touching the other items nearby. The DSS verified the above findings. The DSS stated the opened bags should be stored inside a closed Ziplock bag after it was opened and before placing in the freezer. The DSS further stated the bags should be labeled with the opened date when it was first opened, to determine when the items should be discarded. 2. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall be discarded accordingly. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed the refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: iv. labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen/discarded. On 6/9/25 at 0750 hours, an observation of Refrigerator 1 was conducted with the DSS. The following were observed: - a clear plastic container was observed with limes, cucumbers, oranges, and lemons. The label on the plastic container showed items: lime, cucumber, orange, lemon; received on 5/28/25, and to use-by 6/6/25. - a clear plastic container with carrots inside. The label showed: carrots, prepped on 5/26/25, and use-by 6/7/25. The DSS verified the above findings. The DSS stated the items in the plastic containers should have been removed from the refrigerator and discarded by the use-by date. The DSS stated the kitchen aide was responsible for removing the expired items in the refrigerator, once a week and the evening cook was responsible for checking the refrigerators and freezers during their shift and removing the expired items. 3. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking of the food at the time the food is opened or prepared. The marking system shall include the date of opening, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 15 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 the date the item must be consumed or discarded. Level of Harm - Minimal harm or potential for actual harm On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: Residents Affected - Some - a bag of the cranberry juice connected to the juice dispenser. The bag of juice was not observed labeled with the opened date. The DSS stated she did not know when the juice was opened. - a box of the blush grape juice concentrate connected to juice dispenser. The label on the box showed the opened date of 4/29/25, and the use-by date of 5/29/25. - a box of the apple juice concentrate connected to juice dispenser. The label showed the received date 5/20/25, however the label was undated with the opened or use-by date. The DSS stated she did not know when the juice was opened. - a box of the orange juice concentrate connected to the juice dispenser. The label showed the received date of 5/30/25, however the label was undated with the opened or use-by date. The DSS stated she did not know when the juice was opened. - a bag of thickener liquid connected to the juice dispenser. The bag was not observed labeled with the opened date. The DSS stated did not know when the bag was opened. The DSS verified the above findings. The DSS stated the juices should be discarded after one month of opening. 4. According to the US FDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the US FDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: e. equipment used in the handling of food, including dishes, utensils, mixers. grinders, and other equipment that comes in contact with food. All the equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. Review of the facility's P&P titled Can Opener revised 8/31/18, showed to sanitize the can open after each meal and more frequently if needed. To scrub the shank, paying special attention to the blade and moving parts. To use the sanitizing solution and brush or run through the dish machine. To scrub the base plate (attached to the table). On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - two clear plastic containers containing clean cooking utensils were observed with multiple dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 16 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 particles and debris at the bottom of the bins. Level of Harm - Minimal harm or potential for actual harm - a blue-handled rice scooper observed with yellow colored food residue. - a white-handled rice scooper observed with light brown colored dry food residue. Residents Affected - Some - a portion server observed with dried, white-colored residue. - a stationary can opener observed with dry yellow colored sticky residue on the blade and brownish black colored residue on the can opener gear (the spinning part of the can opener, behind the blade) - multiple steam pans in the dry storage room, observed with dry, white particles on the pans. The DSS verified the above findings. The DSS stated the cooking utensils should be clean and completely dry before placed in the bin. The DSS stated the bins storing the clean kitchen utensils should be completely closed when not in use and the bins should be clean. 5. According to the US FDA Food Code 2022, Section 4-201.11, Equipment and Utensils- Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers. According to the US FDA Food Code 2022, Section 4-202.11, Food-Contact Surfaces, the purpose of the requirements for multi-use food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor or foodborne pathogenic organism. Surfaces which have imperfections such as cracks, chips, or pits allow microorganism to attach and form biofilms. Once established, these biofilms can release pathogens to food. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - one white slotted portion scooper observed with a melted handle. - one white silicone spatula observed chipped and cracked. The DSS verified the above findings and stated the spatula and the portion scooper should be removed and replaced. 6. According to the US FDA Food Code 2022, 3-304.11, Food Contact with Equipment and Utensils, food shall only contact surfaces of: a. equipment and utensils that are cleaned as specified under Part 4-6 of this Code and Sanitized as specified under Part 4-7 of this code; b. single-service and single-use articles. According to the US FDA Food Code 2022, 3-304.12, In-Use Utensils, Between-Use Storage, during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 17 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon; Residents Affected - Some (C) On a clean portion of the food preparation table or cooking equipment only if the in-use utensil and the food-contact surface of the food preparation table or cooking equipment are cleaned and sanitized at a frequency specified under §§ 4-602.11 and 4-702.11; (D) In running water of sufficient velocity to flush particulates to the drain, if used with moist food such as ice cream or mashed potatoes; (E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food; or (F) In a container of water if the water is maintained at a temperature of at least 57 degrees Celcius (135 degrees F) and the container is cleaned at a frequency specified under Subparagraph 4-602.11(D)(7). On 6/9/25 at 0750 hours, during the initial tour of the kitchen, a clear container labeled flour was observed in the emergency food storage room. A plastic cup was observed inside the flour container. The DSS verified the above finding and stated the scoops/cups used to scoop the flour should be kept outside of the container, and not inside. 7. According to the US FDA Food Code 2022, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - a green-handled rice scooper observed stored wet inside the clean kitchen utensils container. - a 4-oz stainless steel measuring cup observed stored wet inside the clean kitchen utensils container. - a stainless-steel spatula observed stored wet inside the clean kitchen utensils container. - three blenders observed stored on the shelf, upright and wet. - one blender lid observed wet, with food particles on the lid. - two steam pans observed stacked, upside down and wet. The DSS verified the above findings and stated the kitchen equipment should be clean and completely dry before stored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 18 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 6/16/25 at 1325 hours, the Administrator, DON, CDM, and DSS were informed and acknowledged the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 19 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility P&P review, and facility document review: Residents Affected - Few * The facility failed to ensure the food item in the residents' refrigerator was properly labeled, dated, and discarded by the use-by date. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food brought in to the facility. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family and Visitors revised 1/30/25, showed it was the right of the residents to have food brought in by family or other visitors, however the food must be handled in a way to ensure the safety of the residents. All food items brought in that are manufactured and do not require refrigeration may be kept in the resident room inside a lock tight container that is provided by the resident and consumed prior to the expiration date. Any expired food must be discarded. 1. On 6/9/25 at 0848 hours, a concurrent observation and interview was conducted with the Activities Director in the dining room. The refrigerator in the dining room was observed with an opened bottle of coconut water labeled 27-A, without a resident's name or identifier. The manufacturer's label showed best if used by 1/16/25, to refrigerate after opening, and to consume within two days. The Activities Director verified the above findings. When asked, the Activities Director stated she did not know when the coconut water was opened. The Activities Director further stated the bottle should be labeled with the resident's name and the opened date. The Activities Director stated the coconut water should have been discarded. On 6/11/25 at 1045 hours, an interview was conducted with the DSD. The DSD stated the food brought from the outside may be refrigerated if the food was appropriate for the resident's ordered diet. The DSD stated the food would be stored in the refrigerator and should be labeled with the resident's name, room number, and the date the item entered the refrigerator. 2. On 6/11/25 at 1014 hours, an interview was conducted with CNA 3. CNA 3 stated food brought from the outside was stored in the refrigerator in the dining room and labeled with the resident's name, room number, and the date the food was brought in. CNA 3 stated the food would be kept in the refrigerator for three days and reheated for the residents. CNA 3 was asked if she had received any safe-food handling education. CNA 3 stated she did not recall any in-services provided regarding the safe-food handling practices of the food brought from outside. CNA 3 further stated she was only provided with in-services on the storage and labeling of the food brought from the outside. On 6/11/25 at 1020 hours, an interview was conducted with CNA 4. CNA 4 stated food brought from outside for the residents was stored in the refrigerator in the dining room. CNA 4 stated if the food needed to be reheated, she would use the microwave located in the dining room. CNA 4 was asked if she had received any education on safe food handling when reheating and serving the food to the residents. CNA 4 stated no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 20 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/11/25 at 1036 hours, an interview was conducted with the IP. The IP stated the food brought from the outside for the residents would be checked for the appropriate diet and texture and stored in the refrigerator in the dining room. The IP further stated the food would be kept in the refrigerator and reheated in the microwave located in the dining room. The IP stated the food would be discarded after three days. The IP stated she did not provide information or education to the residents' family or visitors about the food handling practices when they bring in food from the outside for the residents. On 6/11/25 at 1041 hours, an interview was conducted with LVN 1. LVN 1 was asked if she had received any safe food handling education and if she provided information about safe food handling to the visitors when they bring food from the outside. LVN 1 stated she did not recall receiving any education on safe-food handling and she had only received in-services on ensuring the food brought from the outside were the correct diet and texture, on how to label the food, and where to store the food. On 6/11/25 at 1122 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD reviewed the in-services provided to the facility staff regarding the food brought from the outside and verified the in-services she provided to the facility staff did not cover safe food handling practices of food brought from the outside. On 6/11/25 at 1358 hours, a follow-up interview was conducted with the DSD. The DSD stated the reheating of the food stored in the resident refrigerator was done by the CNAs or licensed nurses. The DSD stated she had not provided any in-services/education to the facility staff about safe food handling practices and the facility did not provide education to the visitors regarding the safe food handling practices of the food brought to the facility. On 6/16/25 at 1325 hours, the Administrator, DON, CDM, and DSS were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 21 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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, facility document review, and facility P&P review, the facility failed to ensure the arbitration agreement was explained in a form, manner, and language the residents or their representatives understood for two of three residents reviewed for the arbitration agreements (one nonsampled resident (Resident 23) and one final sampled resident (Resident 41). This failure posed the risk for the residents to not have a clear understanding of the arbitration process they signed. Residents Affected - Few Findings: Review of the facility's P&P titled Binding Arbitration Agreements revised 1/30/25, showed when explaining the arbitration agreement to the resident or their responsible party, the facility shall explain the form in a manner that he or she understands, including in a language they understand, ensure the resident or their responsible party understands, and that it is their right not to sign the agreement. 1. Medical record review for Resident 41 was initiated on 6/12/25. Resident was admitted to the facility on [DATE]. Review of Resident 41's H&P examination dated 5/2/25, showed the resident had the capacity to understand and make medical decisions. Review of Resident 41's Arbitration Agreement dated 5/8/25, showed the form was signed by the resident and the resident's legal representative. The agreement showed by signing the agreement, the resident was giving up the right to dispute allegations of medical malpractice in the court of law, and must use arbitration (where disputing parties use a third party to make a final decision about their dispute). The agreement also showed it was binding for all the parties including the resident, their heirs, representative, executors, family members, successors, and administrators. On 6/12/25 at 0932 hours, an interview was conducted with Resident 41. Resident 41 stated she did not know what an Arbitration Agreement was and did not understand what the arbitration process was. Resident 41's signature was on the arbitration agreement as well as her representative. On 6/12/25 at 1125 hours, a telephone interview was conducted with Resident 41's responsible party on his understanding of the arbitration agreement and process. Resident 41's responsible party stated he did not recall being told about the arbitration agreement or what the arbitration process was. Resident 41's responsible party stated had they knew what the arbitration meant and it was presented in an understandable manner, he would not have signed the Arbitration Agreement. 2. Medical record review for Resident 23 was initiated on 6/12/25. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 2/1/25, showed the resident had fluctuating capacity to understand and make decisions. Review of Resident 23's Arbitration Agreement dated 1/31/25, showed the form was signed by Resident 23. The agreement showed by signing the agreement, the resident was giving up the right to dispute (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 22 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete allegations of medical malpractice in the court of law, and must use arbitration (where disputing parties use a third party to make a final decision about their dispute). The agreement also showed it was binding for all the parties including the resident, their heirs, representative, executors, family members, successors, and administrators. On 6/12/25 at 0950 hours, an interview was conducted with Resident 23. Resident 23 stated she did not know what the arbitration was and did not understand the process of the arbitration. When Resident 23 was provided with an explanation of the arbitration process, Resident 23 did not verbalize understanding. Event ID: Facility ID: 555266 If continuation sheet Page 23 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record reviews, facility document review, and facility P&P review , the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable diseases and infections. Residents Affected - Few * The facility failed to maintain an accurate infection surveillance program for January and February 2025. Specifically, the Infection Surveillance Monthly Report did not match the data recorded in the facility's Infection Control Summaries for those months. These failures posed a risk of unrecognized resident infections and increased the potential for transmission of communicable diseases throughout the facility. Findings: Review of the facility's P&P titled Antibiotic Stewardship Program dated 1/30/25, showed antibitiotic used shall measure by monthly prevalence, antibiotic starts and/or antibiotic days of the therapy. Data obtained from antibotic stewardship monitoring activityes is dicussed in the facility's QAPI meetings. 1. On 6/12/25 at 1000 hours, a concurrent interview, medical record review, and facility document review was conducted with the IP. The IP was asked what was discussed during the quarterly infection control meeting held in 4/2025. The IP stated they reviewed the antibiotic usage by presenting the infection control summary data for the CAIs and HAIs meeting the McGeer's criteria, and HAIs not meeting the McGeer's criteria for January, February, and March 2025. When asked about the criteria used to identify and track the HAIs, the IP explained the facility used the McGeer's criteria. The infection assessment was generated automatically in Point Click Care when the staff completed the associated questionnaire form. The IP was then asked to provide the infection control surveillance program for January and February 2025 . a. Review of the Infection Control Summary for 1/2025 showed four residents were classified as HAI meeting the McGeer's criteria and four residents did not met the McGeer's criteria. However, the Infection Surveillance Monthly Report Log for January 2025 showed three residents were classified as HAI meeting the McGeer's and five residents as not meeting the McGeer's criteria. For example: For Resident 15, the infection was documented as meeting McGeer's criteria in the Infection Surveillance Monthly Report, however, should have been classified as HAI not meeting the McGeer's criteria. b. Review of the Infection Control Summary for 2/2025 showed: eight residents with CAIs, four residents with HAIs meeting the McGeer's, and nine residents with HAIs not meeting the McGeer's criteria. However, the Infection Surveillance Monthly Report Log for 2/2025 showed there were 11 residents with CAIs, three residents with HAIs meeting the McGeer's, and seven residents with HAIs not meeting the McGeer's criteria. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 24 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few For example: For Resident 51, the infection was listed as CAI in the monthly report, however, was listed as HAI not meeting the McGeer's criteria in the Summary Report. The Infection Surveillance Monthly Report log report was inconsistent with the Infection Control Summary report. For Resident 360, the infection was similarly classified as CAI in the report, however, was listed as HAI not meeting the McGeer's criteria in the Summary Report. The Infection Surveillance Monthly Report log report was inconsistent with the Infection Control Summary report. The IP confirmed the discrepancies identified and stated Resident 15's infection should have been categorized as HAI not meeting the McGeer's criteria. In addition, Residents 51 and 360 should have been classified as CAI and not included in the HAI category. The IP verified the Infection Control Summaries did not match the corresponding Infection Surveillance Monthly Report Logs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 25 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to maintain the essential equipment in a clean and safe operating condition when: Residents Affected - Some * The washing machine detergent dispenser was not maintained in a clean/sanitary condition. This failure had the potential for the essential equipment to not function in the way it was intended and expose residents to unsafe practices. Findings: On 6/16/25 at 0850 hours, an observation of the washing machine detergent dispenser and concurrent interview was conducted with the Maintenance Supervisor. During the observation, the top of the washing machine detergent dispenser's lid was observed left open. Observed was black and white residue found inside the lid of the detergent dispenser. Rust was also found on the lid, and the edge of where the lid should have been closed. When the Maintenance Supervisor was asked about the cleaning of the detergent dispenser's lid and area, the Maintenance Director stated it should have been cleaned with a sanitizer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 26 of 27 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Potential for minimal harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and medical record review, the facility failed to ensure for a safe environment for one nonsampled Resident (Resident 1) as evidenced by: Residents Affected - Some * Resident 1's room was observed with holes on ceiling and near the vent cover * The window screen inside Resident 1's bathroom was observed bent and not fully covering the window. These failures had the potential for pests to enter through these openings. Findings: On 6/11/25 at 0911 hours, two holes were observed on the cork ceiling inside Resident 1's room. Also, the screen for the bathroom window inside Resident 1's room was bent along the top edge, creating a gap. The screen was observed with another gap to the lower right corner of the bathroom window. Medical record review was initiated for Resident 1 on 6/11/25. The resident's medical record showed Resident 1 had no capacity to understand and make decisions. On 6/13/25 at 1130 hours, a concurrent observation and interview was conducted with the Maintenance Director. The Maintenance Director verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555266 If continuation sheet Page 27 of 27