Health inspection·August 4, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to send a copy of the transfer/discharge notice to the Long-Term Care Ombudsman for one of three closed record sampled residents (Resident 54). This posed the risk of the Ombudsman not being aware of the circumstances should an appeal be filed by the resident or their representative regarding the transfer/discharge. Findings: On 8/4/21, closed medical record review was initiated for Resident 54. Resident 54 was admitted to the facility on [DATE], and discharged on 6/4/21, to the general acute care hospital. Review of the Notice of Transfer/discharge date d 6/4/21, showed the section to document if a copy of the notice was sent to State Long-Term Care Ombudsman was not checked off and the date was blank. On 8/4/21 at 1538 hours, an interview was conducted with the SSD. The SSD was asked if the facility provided a copy of the Notice of Transfer/Discharge to the Long-Term Care Ombudsman when the resident was sent to the acute care hospital. The SSD stated she was in charge of sending the notices to the Ombudsman and the documentation of the notification would be found in the medical record. The SSD verified there was no documentation to show the Ombudsman was notified of Resident 54's transfer/discharge. The SSD stated the notification of the Ombudsman was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 2 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Change of Condition dated 3/2021 showed it is the policy of this facility that any significant changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The facility may use the SBAR process to access and evaluate the resident's change of condition. Residents Affected - Few Medical record review for Resident 24 was initiated on 8/2/21. Resident 24 was was initially admitted to the facility on [DATE], and readmitted on [DATE]. On 8/2/21 at 0800 hours, Resident 24 was observed with a dried blood clot on the left side of his lips and had a small amount of blood dripping down his left cheek. On 8/2/21 at 0851 hours, the left side of Resident 24's lips was observed bleeding with a small amount of blood dripping down his left cheek. LVN 5 was asked to come to the resident's room. LVN 5 stated she did not see the bleeding this morning. LVN 5 cleaned the resident with a towel. On 8/3/21 at 1037 hours, after observing bleeding from Resident 24's lips, CNA 3 was asked to come to the resident's room. CNA 3 used the foam oral swab to clean and hydrate the resident's lips. On 8/3/21 at 1040 hours, CNA 3 checked the inside of Resident 24's mouth. CNA 3 stated Resident 24 did not have any bleeding from the gums or inside of the mouth. CNA 3 stated she saw the resident peeling his lips using his fingers last Friday and Monday and stated there was a little bit of bleeding on the resident's lips. CNA 3 stated she forgot to inform the charge nurse and other staff about Resident 24 peeling his lips and the bleeding. CNA 3 stated she knew the resident would peel his lips when he was nervous. On 8/3/21 at 1055 hours, an interview was conducted with LVN 2. LVN 2 stated he saw the resident bleeding yesterday, but did not notify the doctor because there was no more bleeding as the staff had already cleaned the resident. LVN 2 stated he did not assess the inside of the resident's mouth because he was told the bleeding was from the lips. LVN 2 was asked to make an observation of Resident 24. LVN 2 verified the resident was bleeding from the lips and had blood dripping down the left cheek. After informing the physician about the bleeding, LVN 2 received the orders to clean the bleeding site with normal saline and to stop the medication Plavix (blood thinner that can increase the risk of bleeding). When asked why he did not assess the inside of the resident's mouth, LVN 2 stated because he was busy and had to do body checks on the other residents and rounds with three doctors. Review of the Physician and Telephone Order dated 8/3/21, showed to pat the left inner lip bleeding dry every shift for 7 days, obtain stat (immediately) laboratory tests for oral bleeding, and discontinue the Plavix medication. On 8/3/21 at 1408 hours, an interview was conducted with LVN 5. LVN 5 stated she told LVN 2 about the resident bleeding from his lips. LVN 5 acknowledged she did not inform the physician about the bleeding since LVN 2 already knew about it. On 8/5/21 at 1119 hours, an interview was conducted with the DON. The DON was asked about the resident peeling his lip which had caused it to bleed. The DON was unable to find a care plan problem addressing the resident's behavior of peeling his lips. The DON stated the staff should report the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 3 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's behavior and the bleeding to the charge nurse, and the charge nurse should notify the physician of the change of condition and monitor the behavior and address the issue. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for three of 14 final sampled residents (Residents 15, 24, and 34). * The facility failed to obtain Resident 15's lipid panel on 2/18/21, as per the physician's order. * The facility failed to address a change of condition and failed to notify the physician when Resident 24 was observed by CNA 3 and LVN 2 with bleeding from the lips. * The facility failed to ensure Resident 34 was assessed for the use of the bilateral soft cushion in bed. These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's Physician and Telephone Order dated 2/16/21, showed an order to obtain a lipid panel for the resident on 2/18/21. However, review of Resident 15's laboratory results did not show any lipid panel results. Further review of Resident 15's medical record failed to show documented evidence the order for the lipid panel laboratory request was carried out. On 8/5/21 at 1632 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated she did not know why the order for the lipid panel was missed.3. Review of the facility's P&P titled Soft Rails dated 09/2017, showed it is the policy of the facility to assess residents for the least restrictive measures in an attempt to lower their risk for possible falls and/or injury. Under purpose, showed soft rails are an alternative to siderails. However, soft rails are considered restraints. Prior to the use of side rails, the resident requires a comprehensive assessment, physician's orders, informed consent is required to be obtained from the resident or their responsible party and a care plan should be developed to address the use of the restraint. On 8/2/21 at 0924 hours, during an initial tour, Resident 34 was observed lying in the middle of his bed with blue cushions on each side of the bed strapped to the bed frame. Medical record review was initiated on 8/3/21. Resident 34 was admitted on [DATE]. Review of Resident 34's MDS dated [DATE], showed Resident 34 had severely impaired cognition and lower extremity impairment. Review of Resident 34's Physician Order Report dated 7/22/21, showed an order for bilateral soft cushion for positioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 4 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 34's Restraint Assessment and Reduction Management Program dated 6/18/21, did not show Resident 34 was assessed for the use of the soft cushion. Review of Resident 34's Restraint Assessment and Reduction Management Program update, under the IDT Review and Recommendation dated 6/21/21, did not show Resident 34 was reassessed for the use of the soft cushion. On 8/5/21 at 1531 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 34 had the soft cushions for comfort and positioning. RN 1 stated the bilateral soft cushions were needed to help reposition Resident 34. RN 1 stated an assessment was not needed for the use of the soft cushions. On 8/5/21 at 1557 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the soft cushions were used for Resident 34's positioning and comfort. The DON stated an assessment had to be done for the use of the soft cushions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 5 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 31 was initiated on 8/4/21. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. Residents Affected - Few Review of the MDS dated [DATE], showed Resident 31 was cognitively intact and totally dependent on two or more staff members for bed mobility. Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/6/21, showed Resident 31 was at moderate risk for developing pressure ulcers. On 8/4/21 at 1044 hours, a wound treatment observation for Resident 31 was conducted with LVN 2 and CNA 1. Resident 31's left flank, from the left scapula to the left lower rib cage, was observed with a large area of opened skin, measuring 23 cm (length) x 15 cm (width). The flank area was red and had sanguineous drainage, and some areas had bleeding. The whole wound was observed covered in a white substance. The resident's linen was observed spotted with red blood. When asked about Resident 31's left flank, LVN 2 stated he was not aware Resident 31 had the skin breakdown on his left trunk. LVN 2 stated he would call the physician to get the treatment orders for the resident's left flank. LVN 2 was asked what about the white substance observed on the resident's left flank wound. LVN 2 stated the CNA might have put a baby powder on the skin breakdown. Resident 31 was asked when he started having the skin breakdown on his left trunk. Resident 31 stated it started a few weeks ago and caused him discomfort and pain. Resident 31 stated he reported the skin breakdown and pain to the nurses. On 8/4/21 at 1224 hours, an interview was conducted with CNA 3. CNA 3 stated she found Resident 31 with the rashes on his left flank yesterday. CNA 3 stated she notified LVN 2 about the rashes yesterday. CNA 3 stated LVN 2 told her he would apply the powder and the rashes would be better tomorrow. CNA 3 stated the wound was not bleeding yesterday. CNA 3 stated she informed LVNs 2 and 3 about the rashes on Resident 31's left flank today. Review of Resident 31's medical records failed to show an assessment of the resident's left flank skin breakdown was documented, nor was the physician notified of the skin breakdown. On 8/4/21 at 1236 hours, an interview was conducted with LVN 3. LVN 3 stated she was not aware the resident had rashes on his left flank. LVN 3 was asked who responsible for conducting the resident's skin assessments. LVN 3 stated when the CNAs provided ADL care, they would report any new skin breakdown to the licensed nurses. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for three of 15 final sampled residents (Residents 15, 31, and 103). * Resident 15 had no pressure ulcers upon readmission to the facility on 2/6/19. Resident 15 developed the Stage 1 pressure ulcer on the sacral area on 8/18/20, which had deteriorated to Stage 4 on 1/11/21. In addition, Resident 15 developed the Stage 1 pressure ulcer on the right trochanter (any of two bony protuberances by which muscles are attached to the upper part of the thigh bone) on 3/5/21, which had deteriorated to Stage 4 on 3/15/21. The facility failed to ensure the interventions such as turning and repositioning were implemented to prevent the development of pressure ulcers. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 6 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility failed to ensure the wound consultant's recommendations were followed and clarified. The facility failed to provide the appropriate and necessary services to ensure Resident 15 did not develop a pressure ulcer in the facility and failed to ensure the pressure ulcer did not deteriorate. * The facility failed to assess Resident 31's skin breakdown and notify the physician when the skin breakdown on the resident's left flank was identified. * The facility failed to follow through with the wound physician's recommendation for zinc sulfate (supplement) for Resident 103. In addition, the facility failed to ensure Resident 103's heels were offloaded properly. These failures had the potential for the residents to develop pressure ulcers or worsening of existing pressure ulcer(s). Findings: Review of the facility's P&P titled Prevention of Pressure Injuries AKA (also known as) Pressure Sores revised 8/2017 showed pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation or blood flow to an area with subsequent destruction of tissue. Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and addressed. Under the section, Interventions and Preventative Measures, showed for a resident in bed, to change their position at least every two hours or more frequently as needed. Review of the facility's P&P titled Pressure Ulcer/Injury Management revised 6/2019 showed a pressure ulcer/injury is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of intense and/or prolonged pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. The key procedural points included to determine the ulcer/injuries current stage of development. A root cause analysis should be done for each pressure sore. Interventions included nutritional supplements will be provided per physician's orders and residents will be turned/repositioned every two hours or as needed. Review of the National Pressure Ulcer Advisory Panel's (NPUAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers dated 2014 showed maintaining skin integrity is essential in the prevention of pressure ulcers. Repositioning individuals is an important component in the prevention of pressure ulcers. The underlying cause and formation of pressure ulcers is multifaceted; however, by definition, pressure ulcers cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in ischemia and inevitable tissue damage. Repositioning involves a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Individuals who cannot reposition themselves will require assistance. The recommendations included to reposition all individuals at risk of developing pressure ulcers or with existing pressure ulcers. Support surfaces are an important element in pressure ulcer treatment because they provide an environment that enhances perfusion of injured tissue. However, support surfaces alone neither prevent nor heal pressure ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 7 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0686 The NPUAP defines the pressure ulcer stages as follows: Level of Harm - Minimal harm or potential for actual harm - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. Residents Affected - Few - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's Initial Nursing History and assessment dated [DATE], showed Resident 15 did not have any identified skin issues or pressure ulcers upon readmission to the facility. Review of Resident 15's plan of care showed a care plan problem initiated on 7/26/19, addressing Resident 15's risk for skin breakdown. The interventions included frequent position changes while maintaining good body alignment at all times. Review of Resident 15's MDS dated 8/4 and 11/2/20, showed Resident 15 required extensive assistance from two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed). Review of Resident 15's MDS dated 2/2, 4/30 and 7/28/21, showed Resident 15 was totally dependent on two or more staff members for bed mobility. Review of the Interdisciplinary Progress Notes dated 8/18/20, showed Resident 15 was on isolation for COVID-19 infection (coronavirus which can cause severe respiratory illness and death) on 7/27/20, and Resident 15 was noted with the Stage 1 pressure ulcer to the sacral area. Review of the Wound Progress Notes dated 8/18/20, showed Resident 15's Stage 1 pressure ulcer to the sacral area measured 5 cm (length) x 5 cm (width) and had no depth. Review of the Wound Progress Notes dated 1/11/21, showed Resident 15's pressure ulcer to the sacral area deteriorated to Stage 4, measuring 6 cm (length) x 6 cm (width) x 0.3 cm (depth), with undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface). Review of the Wound Progress Notes dated 3/5/21, showed Resident 15 developed a Stage 1 pressure ulcer to the right trochanter pressure injury, measuring 3.5 cm x 3.5 cm and no depth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 8 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Wound Progress Notes dated 3/15/21, showed Resident 15's right trochanter pressure injury deteriorated to Stage 4, measuring 3 cm x 2.5 cm x 2.0 cm, with undermining. Review of the Root Cause Analysis: Pressure Injury Development showed the following: - on 8/17/20, the pressure ulcer was avoidable. The notes included to follow the treatment plan for the sacral pressure ulcer; and - on 3/5/21, the pressure ulcer was avoidable. The notes included to continue treatment as worded and follow-up with the wound care consultation for the right trochanter pressure ulcer. Review of Resident 15's plan of care showed a care plan problem dated 6/15/21, addressing Resident 15's high risk for further skin breakdown. The interventions included to turn and reposition the resident at least every two hours, and administer zinc sulfate 220 mg as ordered. Review of Resident 15's plan of care showed a care plan problem dated 1/11/21, addressing Resident 15's Stage 4 pressure injury to the sacral area. The interventions included a turning and repositioning regimen. Review of Resident 15's plan of care showed a care plan problem dated 5/17/21, addressing Resident 15's Stage 4 pressure injury to the right trochanter area. The interventions included a turning and repositioning regimen. a. On 8/2/21 at 1012, 1123, 1231, and 1429 hours, Resident 15 was observed lying on her back. On 8/3/21 at 1457 hours, an interview was conducted with CNA 4. CNA 4 stated she changed Resident 15's position every two hours. CNA 4 stated she followed the turning schedule to reposition the resident. CNA 4 stated she asked CNA 6 for help when she repositioned Resident 15 at 1200 hours. On 8/3/21 at 1521 hours, an interview was conducted with CNA 6. CNA 6 denied helping CNA 4 to turn Resident 15 at 1200 hours. On 8/4/21 at 1500 hours, an interview was conducted with LVN 2. LVN 2 stated one of the interventions to manage Resident 15's pressure injuries included turning and repositioning her every two hours. When asked how the nurses monitored if Resident 15 was being turned and repositioned, LVN 2 showed a turning schedule and also stated the supervisors checked if the resident were being turned and repositioned. b. Review of the Physician and Telephone Orders showed a physician's order dated 6/23/21, to discontinue the zinc sulfate (a dietary supplement important for the development and health of body tissues) . However, review of the Wound Care Follow-Up Notes dated 6/25, 7/1, 7/9, 7/23, and 7/31/21, under the section for recommendations, showed to administer zinc sulfate (a dietary supplement important for the development and health of body tissues) 220 mg every day. Review of Resident 15's medical records did not show documented evidence the wound consultant's recommendations for zinc sulfate was followed up or clarified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 9 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/5/21 at 1007 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the wound consultant's recommendation for zinc sulfate. The DON stated the wound consultant's recommendations should have been clarified by the treatment nurses. The DON verified there was no documentation the wound consultant's recommendations for zinc sulfate was clarified or followed. 3. Medical record review for Resident 103 was initiated on 8/4/21. Resident 103 was admitted to the facility on [DATE]. a. Review of the physician's orders showed an order dated 7/16/21, for wound care consult for Resident 103's left fifth metatarsal head pressure injury. Review of Resident 103's Wound Care Consults dated 7/19, 7/26, and 8/2/21, under the section for Recommendations, showed zinc sulfate (supplement) 220 mg every day. Further review of Resident 103's medical record failed to show documented evidence the wound consultant's recommendation for zinc sulfate was acted upon. On 8/4/21 at 1243 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated he was not aware of the wound consultant's recommendation to provide zinc sulfate to Resident 103. On 8/4/21 at 1521 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the wound consultant's recommendation for zinc sulfate. The DON stated the recommendation should have been carried out by the treatment nurse. On 8/5/21 at 1800 hours, an interview was conducted with the DON. When asked about when the wound consultant's documentation was provided to the facility, the DON stated the documents were hand carried by the physician or nurse practitioner on their subsequent visit. b. Review of Resident 103's Physician's Orders Treatment dated 6/9/21, showed Resident 103 was admitted with the following skin problems: - Stage 1 right fifth metatarsal tuberosity pressure injury (characterized by superficial reddening of the skin that when pressed does not turn white) - Stage 1 left lateral malleolus pressure injury - Deep tissue injury to the left fifth metatarsal head (the bony prominence on each side of the human ankle) - Deep tissue injury to the left fifth lateral toe deep tissue injury - Stage 1 left fifth metatarsal tuberosity pressure injury - Stage 1 left lateral (outer side) heel pressure injury - A blister to the left thigh Review of Resident 103's Pressure Injury/Ulcer/Poor Skin Integrity form dated 6/10/21, under recommendations, showed to offload (minimizing or removing weight placed on the foot to prevent and heal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 10 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0686 ulcers) foot with pillows. Level of Harm - Minimal harm or potential for actual harm Review of the care plan addressing altered skin integrity related to pressure injury to the left fifth metatarsal head dated 6/10/21, showed an intervention to offload Resident 103's foot with pillows. Residents Affected - Few Review of Resident 103's Wound Progress Notes dated 6/12/21, showed to off load to heels. On 8/4/21 at 0906 hours, a treatment observation was conducted with LVN 2 for Resident 103. Resident 103's right heel was observed resting on a pillow. At the end of the treatment, Resident 103's left foot was placed on top of a pillow. When asked if the heel had to be offloaded, LVN 2 stated it was okay for Resident 103's heel to be resting on the pillow. On 8/4/21 at 1135 hours, an interview was conducted with RN 1. RN 1 stated Resident 103 was turned every 2 hours and heels should be off loaded. When asked what offloading of the heels meant, RN 1 stated the foot should be hanging at the edge of the pillow. On 8/4/21 at 1446 hours, an observation and concurrent interview was conducted with RN 1. Resident 103's right heel was observed on top of the pillow. RN 1 stated Resident 103's right heel was properly offloaded when the heel was resting on top of the pillow and was not touching the mattress. On 8/4/21 at 1521 hours, an interview and concurrent record review was conducted with the DON. When asked what offloading of Resident 103's heel meant, the DON stated the heels should be free from touching the pillow. The DON stated Resident 103 was at risk for developing pressure ulcers and both heels should be offloaded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 11 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure adequate assistance was in place for one of 14 final sampled residents (Resident 15). This posed the potential for Resident 15 to sustain a fall or injuries. Findings: Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 15 had severe cognitive impairment. Resident 15 required total assistance from two or more persons for bed mobility and transfers. The assessment showed Resident 15 had functional limitation of the upper and lower extremities. Review of Resident 15's plan of care showed a care plan problem revised 4/30/21, addressing Resident 15's risk for fall or injury related to poor safety awareness, impaired balance, gait problem, and required assistance with transfers. Further review of the plan of care showed a care plan problem revised 4/30/21, addressing Resident 15's impaired physical mobility and self-care deficit related to Resident 15 requiring two persons' assistance for bed mobility and transfers. Review of Resident 15's Point of Care History dated 7/30 to 8/5/21, showed inconsistencies of the number of staff support provided for bed mobility. For example, - a score of 2 on 7/30/21 at 0249 and 1701 hours; 7/31/21 at 0244, 1037, and 2244 hours; 8/1/21 at 0112, 0955, and 0952 hours; 8/2/21 at 1236 and 1804 hours; 8/3/21 at 1259 and 1802 hours; 8/4/21 at 1255 and 1630 hours; and 8/5/21 at 1241 hours. - a score of 3 on 8/2/21 at 0914 hours, 8/3/21 0841 hours, 8/4/21 at 1033 hours, and 8/5/21 at 0951 hours. On 8/3/21 at 1457 hours, an interview was conducted with CNA 4. When asked how many persons Resident 15 needed to assist with repositioning, CNA 4 stated she repositioned Resident 15 by herself at 1000 and 1400 hours. CNA 4 stated she asked assistance from CNA 6 at 1200 hours, to reposition Resident 15. On 8/3/21 at 1523 hours, an interview was conducted with CNA 6. When asked if she helped CNA 4 to reposition Resident 15, CNA 6 denied helping CNA 4. CNA 6 stated she had helped another CNA with another resident, not CNA 4 at 1200 hours. On 8/5/21 at 1213 hours, an interview and concurrent medical record review for Resident 15 was conducted with the MDS Assistant. The MDS Assistant verified Resident 15 required total assistance from two or more persons for bed mobility and transfers. The MDS Assistant stated bed mobility included turning and repositioning. When asked why Resident 15 needed to have two persons' assistance for repositioning or incontinence care, the MDS Assistant stated to prevent the resident from falling off the bed. The MDS Assistant the CNAs documented in the Point of Care History every shift. The MDS Assistant verified Resident 15's Point of Care History showed scores of 2 to 3. The MDS Assistant stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 12 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a score of 2 meant only one person assistance provided to Resident 15 and a score of 3 meant a two persons' assistance provided to the resident. The MDS Assistant acknowledged the staff documented only one person assistance was provided to Resident 15 on multiple shifts from 7/30 to 8/5/21, in Resident 15's Point of Care History. On 8/5/21 at 1534 hours, an interview was conducted with CNA 5. When asked how many persons Resident 15 needed to assist with repositioning, CNA 5 stated Resident 15 only needed a one-person assist. When asked how she would know the assistance required for Resident 15, CNA 5 stated she was told Resident 15 only needed one person assistance, and they also documented that Resident 15 only needed one-person assist. Event ID: Facility ID: 555329 If continuation sheet Page 13 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0698 Provide safe, appropriate dialysis care/services 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 observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for one of 14 final sampled residents (Resident 152) who required dialysis. Residents Affected - Few * The facility failed to ensure the physician's order for a 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. This had the potential to result in Resident 152 having excess fluids which may affect other vital organs in the body due to impaired kidney function. Findings: Medical record review for Resident 152 was initiated on 8/5/21. Resident 152 was admitted to the facility on [DATE], with End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) required hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally). Review of the history and physical examination dated 7/25/21, showed Resident 152 had the capacity to make decisions. Review of Resident 152's physician's orders showed an order dated 8/3/21, for fluid restriction of 1000 ml/24 hours (dietary was to provide 600 ml and nursing was to provide 400 ml). Review of the care plan problem addressing dialysis dated 8/3/21, showed Resident 152's fluid restriction was 1000 ml per 24 hours as follows: * For nursing to provide 400 ml of fluid: - 100 ml for the 11-7 shift - 200 ml for the 7-3 shift, - 100 ml for the 3-11 shift * For dietary to provide 600 ml of fluid: - 240 ml at breakfast - 120 ml at lunch - 240 ml at dinner On 8/5/21 at 0800 and 0930 hours, a green water pitcher filled with water was observed by Resident 152's bedside. On 8/5/21 at 1234 hours, an interview was conducted with Resident 152. When asked if she was aware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 14 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of her fluid restriction, Resident 152 stated she was currently on 1800 ml of fluids per 24 hours. When asked about the water pitcher at bedside, Resident 152 stated she would pour herself water and would consume the water in the pitcher by the end of shift. Resident 152 stated her water pitcher would be refilled with fresh iced water every shift. On 8/5/21 at 1245 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 152 was on fluid restriction. CNA 8 verified the water pitcher by Resident 152's was filled with water. On 8/5/21 at 1248 hours, Resident 152 was served lunch and her tray card showed 1800 ml fluid restriction. On 8/5/21 at 1248 hours, a concurrent observation and interview was conducted with LVN 5. LVN 5 stated she was aware of Resident 152's fluid restriction. LVN 5 stated Resident 152 had an order to restrict her fluids at 100 ml/24 hours. LVN 5 verified Resident 152's tray card showed 1800 ml fluid restriction. LVN 5 verified the water pitcher filled with water on Resident 152's bedside table. LVN 5 stated the water pitcher at Resident 152's bedside had to be removed. On 8/5/21 at 1740 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 15 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **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 ensure one of 14 final sampled residents (Resident 103) and one nonsampled resident (Resident 21) were assessed for entrapment associated with the use of elevated grab bars and informed consent was obtained for the use of the grab bars. * The facility failed to ensure the assessments for the risk for entrapment were completed for Residents 21 prior to the use of grab bars. In addition, the facility failed to develop a plan of care addressing the use of grab bars. * The facility failed to ensure Resident 103 was assessed for the risk of entrapment nor an informed consent was obtained for the use of the grab bars. These failures had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Bed rails are adjustable metal or rigid plastic bars that attach to the bed and are available in a variety of shapes and sizes from full to half, one-quarter, and one-eighth in lengths. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Siderail or Bedrail Assessment Guidance to Reduce Entrapment revised 8/2018 showed it is the policy of the facility to assess a resident's risk for entrapment prior to the installation of siderails or bedrails to ensure that the beds dimensions are appropriate for the resident's size and weight. The facility will assess the resident's risk for entrapment for the use of a grab bar using the facility's grab bar assessment. 1. On 8/4/21 at 0836 and 1134 hours, Resident 21 was observed lying in bed with bilateral grab bars elevated. Medical record review for Resident 21 was initiated on 8/2/21. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's MDS dated [DATE], showed Resident 21 had a severely impaired cognition and impairment of both upper and lower extremities. Review of Resident 21's Informed Consent for a Grab Bar as an Enabler/Assistive Device dated 8/20/20, showed Resident 21's representative gave consent to the use of the grab bars. Review of Resident 21's Restraint Assessment and Reduction Management Program dated 8/14/20, did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 16 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0700 not show Resident 21 was assessed for the use of the grab bars. Level of Harm - Minimal harm or potential for actual harm Review of Resident 21's Restraint Updates dated 11/7/20, 2/6, and 5/14/21, did not show Resident 21 was assessed for the use of the grab bars. Residents Affected - Few Review of Resident 21's plan of care did not show a care plan problem was developed to address the use of the grab bars. Further review of Resident 21's medical record showed no documented evidence Resident 21 was assessed for entrapment prior to the use of the grab bars. On 8/4/21 at 1317 hours, an observation, interview, and concurrent medical record review for Resident 21 was conducted with the DON. Resident 21 was observed lying in bed with bilateral grab bars elevated. The DON stated she did not know why Resident 21's grab bars were elevated. The DON verified Resident 21 was not assessed for the risk for entrapment prior to the use of the grab bars. The DON verified there was no care plan to address the use of the grab bars. 2. Medical record review for Resident 103 was initiated on 8/3/21. Resident 103 was admitted on [DATE]. Review of History and Physical Examination dated 6/10/21, showed Resident 103 had severe cognitive impairment. Review of Resident 103's Restraint Assessment and Reduction Management Program form dated 6/9/21, under the section approaches, showed to provide low bed, pillows and bed on a low position only. Resident 103 was not assessed for the need of grab rails and risks of entrapment from the use of grab rails. Further review of Resident 103's medical record did not show a consent for the use of the grab rails. In addition, Resident 103's care plans did not address Resident 103's grab rail use. On 8/2/21 at 0913 hours, during an initial tour, Resident 103 was observed lying on her back, watching television. Resident 103's upper extremities was observed to have contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The grab rail on the right side of Resident 103's bed was observed to be elevated. On 8/4/21 at 1521 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 103 was assessed for the use of the grab bars The DON stated Resident 103 was not supposed to have the grab bars. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 17 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications in order to prevent loss, diversion, or accidental exposure. Residents Affected - Few * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Cart B consistently signed the Narcotic Count Sheet log. This failure created the risk of drug diversion in the facility. Findings: According to the facility's Policy and Procedure titled Controlled Medication Storage dated 8/2014, under the section Policy, showed medication included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Under the section Procedures, showed at each shift change, a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record. Review of Medication Cart B's Narcotic Count Sheet showed multiple missing licensed nurses' signatures on the following dates: - 5/3/21, for the 11-7 incoming shift and 7-3 outgoing shift - 5/4/21, for the 11-7 incoming shift, 7-3 outgoing shift and 7-3 incoming shift - 5/6/21, for the 7-3 outgoing shift and 3-11 incoming shift - 5/7/21, for the 11-7 outgoing and incoming shift, 7-3 outgoing shift and 3-11 incoming shift - 5/10/21, for the 11-7 incoming shift - 5/11/21, for the 11-7 incoming shift and 7-3 outgoing shift - 5/12/21, for the 7-3 outgoing shift - 5/17/21, for the 11-7 incoming shift and 7-3 outgoing shift - 5/18/21, for the 11-7 incoming shift and 7-3 outgoing shift - 5/21/21, for the 7-3 outgoing shift - 5/28/21, for the 11-7 incoming shift and 7-3 outgoing shift - 5-30/21, for the 11-7 incoming shift and 7-3 outgoing shift - 6/4/21, for the 11-7 outgoing shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 18 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 - 6/9/21, for the 3-11 incoming shift and 11-7 outgoing shift Level of Harm - Minimal harm or potential for actual harm - 6/12/21, for the 3-11 outgoing shift - 6/17/21, for the 7-3 outgoing shift and 3-11 incoming shift Residents Affected - Few - 6/18/21, for the 11-7 outgoing shift On 8/3/21 at 1446 hours, an interview and concurrent facility document record review was conducted with LVN 3. LVN 3 verified multiple licensed nurses' signature missing in the Narcotic Count Sheet log. When asked what the Narcotic Count Sheet log was for, LVN 3 stated the incoming and outgoing nurses counted the medications at the end of shift to ensure the narcotic medication counts were reconciled and accounted for. On 8/3/21 at 1740 hours, an interview and facility record review was conducted with the DON. The DON verified multiple missing entries on Medication Cart B's Narcotic Count Sheet log for May 2021 and June 2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 19 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 14 final sampled residents (Resident 15). The Pharmacy Consultant recommended for a lipid panel test (complete cholesterol test, a blood test that can measure the amount of cholesterol and triglycerides in the blood) for the use of simvastatin (medication used to treat high cholesterol and triglyceride levels) was not acted upon. The facility's failure to act upon the Pharmacy Consultant's recommendations had the potential to put Resident 15 at risk for adverse consequences related to the medication. Findings: Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's Physician Order Report showed a physician's order dated 7/26/19, for simvastatin 10 mg to be given at bedtime. Review of the Medication Administration Record for June, July, and August 2021 showed Resident 15 received the simvastatin medication daily. Review of the Note to Attending Physician/Prescriber (pharmacy consultation report) for Resident 15 dated 6/14/21, showed a request for lipid panel test for the use of simvastatin. The area for the physician/prescriber response whether to agree or disagree with the recommendation was left blank. Review of Resident 15's medical record did not show any lipid panel test ordered for Resident 15. Further review of Resident 15's medical record did not show whether the Pharmacy Consultant's recommendation for lipid panel test was communicated to the physician. On 8/5/21 at 1555 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 2. RN 2 was asked how the facility informed the prescribing physician about the Pharmacy Consultant's recommendations, RN 2 stated they called the physician to inform of the Pharmacy Consultant's recommendation. RN 2 stated if the physician agreed to the recommendation, then the licensed nurses carried it out. RN 2 stated they would fax a copy of the pharmacy consultation reports to the physician's office and place a copy of the pharmacy consultation report in the resident's medical record. When asked how soon the facility should follow-up on the Pharmacy Consultant's recommendations, RN 2 stated as soon as they received the consultation reports, but usually within 72 hours. RN 2 verified the Pharmacy Consultant's recommendation for lipid panel test for the use of simvastatin dated 6/14/21, was not acted upon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 20 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 14 final sampled residents (Resident 15) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the side effects were monitored for the administration of valproic acid (anticonvulsant, medication used to treat seizures and bipolar disorder). This had the potential for Resident 15 to have adverse complications from the medication. Findings: Medical record review for Resident 15 was initiated on 8/2/21. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's Physician Order Report showed the following physician's orders dated: - 10/18/19, to monitor episodes of calling out for no apparent reason every shift and tally by hashmarks; and - 9/30/20, to administer valproic acid 125 mg at bedtime for schizoaffective disorder bipolar type manifested by episodes of calling out for no reason. Review of the Medication Administration Record for June, July, and August 2021 showed Resident 15 received valproic acid medication daily. Review of Resident 15's medical record showed no documented evidence the side effects of valproic acid were monitored. On 8/5/21 at 1007 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When asked about monitoring the side effects of valproic acid, the DON could not locate any documentation showing Resident 15 was monitored for the side effects of valproic acid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 21 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was below 5%. The facility's medication error rate was 28.57%. Residents Affected - Few * LVN 3 failed to administer Resident 9's medications in a timely manner. This failure posed the risk of complications and ineffective therapeutic effects of the medications. Findings: According to the facility's policy titled Preparation and General Guidelines: Medication Administration General Guidelines dated October 2017, under administration, showed medications are administered within 60 minutes of scheduled time (one hour before and one hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. On 8/4/21 at 1112 hours, a medication administration observation was conducted with LVN 3 for Resident 9. LVN 3 stated Resident 9's medications were due at 0900. LVN 3 prepared the following medications: - 20 ml of Vimpat (medication for seizures) 10 mg/ml solution, - one tablet of Senna (medication for constipation) 8.6 mg, - 30 ml of carbamazipine (medication for seizures) 100 mg/5 ml, - one tablet of Ativan (medication for anxiety) 0.5 mg, - 5 ml of Vitamin C (supplement), - 25 ml of docusate sodium (bowel management) 50 mg/5 ml, - one tablet of Vitamin B-6 (supplement) 50 mg, - 7.5 ml of iron (supplement) liquid 220 mg/5 ml, - 15 ml of Keppra (medication for seizure) 100 mg/5 ml, and - 1/2 inch ribbon of Nitrobid (medication for angina) ointment. On 8/4/21 at 1133 hours, an interview was conducted with LVN 3. When asked about the time when Resident 9's medications were administered, LVN 3 stated Resident 9's medications were supposed to be given at 0900 hours. LVN 3 stated she was busy with other residents' appointments and missed the time. LVN 3 stated the medications had to be administered one hour before or one hour after the scheduled time. On 8/5/21 at 1800 hours, an interview was conducted with the DON. The DON stated the residents' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 22 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0759 medications may be given one hour before or one hour after the prescribed time frame. The DON verified Resident 9's medications had to be administered on time and as scheduled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 23 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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, and facility P&P review, the facility failed to implement their infection control P&P designed to prevent the spread of infection in the facility. Residents Affected - Few * The facility failed to ensure LVN 6 wore a faceshield in the resident care areas. In addition, the facility failed to ensure the faceshield was stored or discarded properly. * Multiple medication bottles in Medication Cart A had stains and sticky residues. The medication drawer holding the liquid medications in Medication Cart A had sticky residues. These failures had the potential for the spread of infection in the facility. Findings: Review of the facility's Corona Virus Disease 2019 (Covid 19) Mitigation Plan revised 7/30/21, under Personal Protective Equipment, showed to use universal face mask and eye protection while in the facility and resident care areas. 1. On 8/4/21 at 0833 hours, LVN 6 was observed going inside Room A. LVN 6 was observed wearing a mask but not wearing a faceshield. On 8/4/21 at 0838 hours, LVN 6 was observed going inside Room C. LVN 6 was observed wearing a mask but not wearing a faceshield. On 8/4/21 at 0850 hours, LVN 6 was observed going inside Room B. LVN 6 was observed wearing a mask but not wearing a faceshield. On 8/4/21 at 0854 hours, an interview was conducted with LVN 6. LVN 6 acknowledged he did not wear a faceshield, when he went inside Rooms A, B, and C. LVN 6 stated he passed the medications to the residents in the rooms. LVN 6 stated he knew he was supposed to wear a faceshield in the resident care areas. LVN 6 stated he discarded his faceshield at the start of the shift and did not request for a new one. 2. On 8/4/21 at 0840, 0849, and 0900 hours, a faceshield was observed hanging by the computer area in the hallway. On 8/4/21 at 0906 hours, an interview was conducted with the IP. The IP was informed of the above findings. The IP stated the staff was to wear the mask and faceshield in the resident care areas including when passing medications to the residents. The IP also verified a faceshield was hanging by the computer area in the hallway. On 8/5/21 at 1712 hours, a follow-up interview was conducted with the IP. When asked how the facility staff should store or discard their faceshields, the IP stated they sanitized their faceshield after the shift and stored in their own separate bins. The IP stated the staff could discard their faceshields in the trash can. 3. According to the facility's P& P titled Storage of Medications dated April 2008, under the section Procedures, showed medication storage areas are kept clean, well-lit, and free of clutter and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 24 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 extreme temperatures. Level of Harm - Minimal harm or potential for actual harm On 8/3/21 at 1430 hours, an inspection was conducted on Medication Cart A with LVN 1. The following was observed: Residents Affected - Few - one Vitamin C liquid bottle with yellow sticky residue all over the bottle and bottle cap, - one Ultratuss DM bottle with pinkish stains and sticky residue outside of bottle and the bottle cap, - one trihexyphenidyl hydrochloride oral solution bottle with dried, white residue on the bottle and bottle finish, and; - the bottom drawer of Medication Cart A had sticky materials and medication residues. LVN 1 verified the medication bottles had stains and sticky residues. LVN 1 stated all nurses who used the medication cart were responsible in maintaining cleanliness. On 8/5/21 at 1800 hours, the DON was informed of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 25 of 26 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain an effective pest control program. Residents Affected - Few * The fire exit door at Nurses' Station B was observed to be left ajar. In addition, a gap was observed at the bottom portion of the fire exit door and floor threshold. An open cracked area on the left lower corner of the fire exit door was observed. These failures posed the risk for vermin entering the facility and potential safety hazard for the residents, staff, and visitors. Findings: On 8/2/21 at 0900 hours, a concurrent observation and interview was conducted with the IP. The fire exit door located at the end of the hallway in Nurses' Station B was observed to be left open. In addition, an open cracked area was observed on the left lower corner of the fire exit door. A gap was also observed between the bottom of the fire exit door and the floor threshold. The IP verified the findings and stated the exit door had to remain shut at all times. Review of the Orkin Pest Control Down to a Science Invoice dated 5/26/21, showed sightings of cockroaches in the employee bathroom in Nurses' Station B and Room D. On 8/4/21 at 1000 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated the fire exit door's lock was not closing completely. The Maintenance Director stated the exit door should be always closed. The Maintenance Director verified the open cracked area and the gap on the fir exit door, and stated the gap had to be covered to prevent roaches and pest to come inside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555329 If continuation sheet Page 26 of 26