Health inspection·August 8, 2025

F 0554 - a physician's order Level of Harm - Potential for minimal harm - self-administration of medication assessment - IDT notes Residents Affected - Some - a care plan addressing Resident 2's self- administration of medication On 8/7/25 at 1457 hours, an interview and concurrent medical record review for Resident 2 was conducted with Treatment Nurse 1. Treatment Nurse 1 verified Resident 2 did not have a physician’s order, assessment, and care plan to address the safe self-administration of the medications, including the medicated cream. On 8/7/25 at 1545 hours, the DON was informed and verified the above findings. 2. On 8/8/25 at 0844 hours, during the tour of the facility, Resident 4 was observed with four pieces of Halls cough drops on the resident’s bedside table. LVN 2 was in the hallway outside the resident’s room and was asked to come inside the resident’s room for an interview. When asked if the Halls cough drops were considered medications, LVN 2 stated he was not sure and would get back with a response. On 8/8/25 at 0852 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated he verified with RN 2 and RN 2 informed him the Halls cough drops were considered candy. On 8/8/25 at 0856 hours, LVN 2 provided the packaging where the Halls came from. The Halls packaging showed Halls Sugar Free to relieve cough, soothes the throat, and cools nasal passages. The Halls packaging also showed Menthol 5.8 mg. LVN 2 verified the findings and stated Resident 4 should not have had the cough drops at her bedside and needed to have permission from the physician, documented in the progress notes and care plan, and self-administration of medications needed to be filled out. LVN 2 verified Resident 4 was not assessed for safe self-administration of medications, no care plan initiated, and no physician’s order was obtained for self-administration of medication. Medical record review for Resident 4 was initiated on 8/8/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4’s H&P examination dated 7/31/25, showed the resident was alert, oriented and cognitively intact. Further review of Resident 4's medical record failed to show documented evidence of the following for Resident 4 to safely self-administer medications including: - a physician's order - self-administration of medication assessment - IDT notes - a care plan addressing Resident 4’s self- administration of medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555308 If continuation sheet Page 2 of 5 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 555308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630 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 0554 Level of Harm - Potential for minimal harm On 8/8/25 at 1448 hours, an interview was conducted with Resident 4. Resident 4 stated a friend brought it to her and she took one Halls cough drop every night by herself. Resident 4 further stated she did not inform anyone when she was going to take it. On 8/8/25 at 1545 hours, the Administrator and DON were informed and acknowledged the above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555308 If continuation sheet Page 3 of 5 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 555308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure a care plan was developed to address an incident between Janitor 1 and one of six sampled residents (Resident 6). The Maintenance Director and Janitor 1 failed to notify the charge nurse and the DON timely when Resident 6 had a verbal outburst towards Janitor 1 when she was asked to leave the laundry room for safety reasons. This failure placed the resident at risk for not having individualized interventions to address the resident's behavior. Findings: On 8/8/25 at 0913 hours, during the initial tour of the facility, an interview was conducted with Resident 6. Resident 6 stated Janitor 1 has been stalking her. Resident 6 stated she went down to the laundry room about three months ago because she ran out of clothes. Once in the laundry room, Janitor 1 told Resident 6 to leave, and she could not be down there. Resident 6 then stated Janitor 1 followed her to her room and she told him to leave her alone. Resident 6 stated the stalking happened about two months. Resident 6 stated she was speaking with another resident and claimed Janitor 1 came up and started talking to the other residents she was talking to. Resident 6 stated Janitor 1 has been told to not go near her; however, came into her room on a different occasion. Resident 6 claimed LVN 3 may have known about it. On 8/8/25 at 0951 hours an interview was conducted with the Administrator and DON. The Administrator and DON were notified of the allegation Resident 6 made against Janitor 1. The DON stated she was made aware by the Maintenance Director about a month ago about Resident 6 not being comfortable with Janitor 1 and Janitor 1 was asked not to go inside her room anymore. However, the DON stated she was not aware of the allegation made by Resident 6. When the DON was asked if she was aware of the reason as to why Resident 6 was not comfortable with Janitor 1, the DON stated no. When asked if the facility had documentation of the report received from the Maintenance Director, the DON stated it was all verbal. The DON claimed she was informed by the Maintenance Director about Janitor 1 accidentally went inside the room of Resident 6 to get the trash. On 8/8/25 at 1018 hours, a concurrent interview was conducted with the Maintenance Director, Administrator, and DON. The Maintenance Director stated Janitor 1 informed him a CNA took Resident 6 to the laundry room and left her there. Janitor 1 told Resident 6 she could not be in the laundry room and Resident 6 started cursing at Janitor 1 and telling him she could do what she wanted because she lived there. The Maintenance Director stated the incident happened about a month ago and claimed Janitor 1 reported the incident to him the following day. When asked if the incident was reported to the DON, the Maintenance Director stated he did not recall if he told all the details at the time. The Maintenance Director also stated he informed Janitor 1 to not go to Resident 6's room; however, because Janitor 1's responsibility included taking out the trash from the residents' room, it was a routine for Janitor 1 to go inside the rooms and accidentally walked inside Resident 6's room to take out the trash. Once Janitor 1 walked into Resident 6's room, he left the room and informed the Maintenance Director. The Maintenance Director informed the DON. When asked if Janitor 1 informed the nursing staff, the Maintenance Director stated he did not recall if Janitor 1 reported the incident to anyone else. The Maintenance Director further stated Janitor 1 felt he did not need to escalate the situation to the Administrator or the DON. When the DON was asked if the staff member may leave the residents in the laundry room by themselves, the DON stated the family or residents may go down to the laundry. If the resident was alert, oriented, and ambulatory, the staff may endorse the resident to go in the laundry room if there was also a staff present at the time. When the DON was asked if the facility documented when a concern was brought up, the DON stated the facility was meant to document; however, the DON stated she was not informed by a charge nurse or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555308 If continuation sheet Page 4 of 5 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 555308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete CNA about an incident between Janitor 1 and Resident 6. Medical record review for Resident 6 was initiated on 8/8/25. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 2/13/25, showed the resident was alert and oriented times three, had normal cognition, and had the capacity for healthcare decisions. Further review of Resident 6's medical record did not show documentation of the incident between Janitor 1 and Resident 6. There was no documented evidence a care plan was developed to address the incident and Resident 6's behavior episode towards Janitor 1, to include interventions to prevent another incident between Janitor 1 and Resident 6. On 8/8/25 at 1104 hours, an interview was conducted with LVN 3. Resident 6 identified LVN 3 as the staff who may have had knowledge of the incident between her and Janitor 1. When asked if he was made aware Resident 6 went down to the laundry room with a CNA, LVN 3 stated he did not recall hearing about the situation. When asked if he recalled if Resident 6 had an issue with the laundry, LVN 3 stated he did not recall. LVN 3 stated Resident 6 informed him Janitor 1 did not knock before entering her room to clean. LVN 3 also stated he did not recall if he was told Janitor 1 could not be near Resident 6. On 8/8/25 at 1423 hours, a telephone interview was conducted with Janitor 1. Janitor 1 stated he was in the laundry room re-supplying his cart and saw Resident 6 and a male nurse near the doors to the laundry room in the dining room. Janitor 1 stated he told the male nurse if he could take the resident; however, the nurse stated he could not. Janitor 1 also stated there was a new laundry aide who did not know the residents were not allowed to be inside the laundry room, therefore, Janitor 1 explained to the new laundry aide. Janitor 1 informed Resident 6 she could not be in the laundry room, and she had to leave. Janitor 1 stated Resident 6 then started being racist towards him and cursing at him after he asked her to leave and stated she could do what she wanted because she lived there. Janitor 1 stated he did not know who the resident was at the time, and he made the report to the Maintenance Director. Janitor 1 stated the situation between him and Resident 6 happened on a Saturday, texted the Maintenance Director on Saturday to inform him about the situation, and the Maintenance Director told Janitor 1 to tell him about it on Monday. Janitor 1 stated he went to the nursing station to ask who the resident was because he did not know the resident's name; however, did not inform a nurse about what happened. Janitor 1 acknowledged last week, while doing housekeeping, he forgot he was not to go to Resident 6's room to clean and Resident 6 got mad at him, and he left and informed the Maintenance Director about what happened. Janitor 1 stated he never followed Resident 6 to her room, or around the facility. Janitor 1 stated he went to the nursing station to figure out the resident's name but did not tell the charge nurse what happened in the laundry room. On 8/8/25 at 1545 hours, the Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 555308 If continuation sheet Page 5 of 5