Health inspection·November 26, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete examination dated 11/14/25, showed Resident 66 had the capacity to understand and make decisions. Review of Resident 66's plan of care failed to show a care plan problem was developed to address Resident 66's self-administration of the Renvela medication. 2. On 11/19/25 at 0838 hours, during the initial tour of the facility, Resident 68 was observed lying in bed, with a bottle of a nasal spray on her overbed table. Resident 68 stated the bottle of nasal spray was her own supply and she had been self-administering the nasal spray three times a day. On 11/19/25 at 1024 hours, a follow-up observation was conducted for Resident 68. Resident 68 was observed lying in bed with a bottle of nasal spray on her overbed table. On 11/19/25 at 1033 hours, an observation for Resident 68 and concurrent interview was conducted with LVN 4. LVN 4 verified a bottle of nasal spray was observed on Resident 68's overbed table. Medical record review for Resident 68 was initiated on 11/19/25. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's Self-Administration of Medication assessment dated [DATE], showed Resident 68 did not want to self-administer medications, had a diagnosis that may interfere with the ability to self-administer and not physically able to administer medications. The assessment further showed Resident 68 was not a candidate for safe self-administration of medications. Review of Resident 68's plan of care failed to show a care plan problem was developed to address Resident 68's self-administration of the nasal spray. Review of Resident 68's medical record failed to show a physician's order for the administration of the nasal spray. On 11/25/25 at 1325 hours, an interview and concurrent medical record review for Residents 66 and 68 was conducted with the DON. The DON verified the above findings. The DON verified Residents 66 and 68 were not safe to self-administer their own medications per the Self-Administration of Medication assessment. The DON further verified there were no physician's order to self-administer the medications and care plan addressing the residents' self-administration of the medications. The DON stated if a resident was assessed to be able to self-administer his/her own medication, there should be a physician's order for the resident's self-administration of the medication, and this should be addressed in the resident's care plan. The DON further stated if a resident was assessed to be able to self-administer his/her own medication, the medications were stored inside the medication cart and would be given to the resident when it was time to take the medication. The DON also stated the nurses should not leave the medication at the resident's bedside and were supposed to be monitored while the resident takes the medication. Event ID: Facility ID: 555391 If continuation sheet Page 2 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review, and facility P&P review, the facility failed to ensure the necessary means to call the staff for assistance was provided for one of 12 final sampled residents (Resident 27). * The facility failed to ensure the call light was visible and within Resident 27's reach. This failure posed a risk for the delay of care/assistance when the resident is unable to call for help. Findings: Review of the facility's P&P titled Call Light dated 11/16/24, showed to leave the resident comfortable and place the call device within resident's reach call cords clipped on the pillow/bed sheet) before leaving room. On 11/19/25 at 0910 hours, during the initial tour of the facility, Resident 27 was observed grimacing in bed. When asked how was she, Resident 27 responded, I'm shaking because I want to go to the bathroom, I don't know where my call light is. The staff was called for help, CNA 3 responded and assisted Resident 27. Upon transfer of Resident 27 from the bed to the wheelchair, the call light was observed by Resident 27's left upper thigh covered with a blanket and bed sheet. Resident 27 stated the call light was not visible and he was not able to use it. On 11/19/25 at 0915 hours, an interview was conducted with CNA 3. CNA 3 acknowledged Resident 27's call light was not visible to the resident and was located by the resident's left upper thigh, covered with the blanket and bed cover sheet. CNA 3 stated the call lights should be visible and within the resident's reach. Medical record review for Resident 27 was initiated on 11/19/25. Resident 27 was admitted on [DATE]. Review of Resident 27's H&P examination dated 11/11/25, showed Resident 27 had no capacity to make medical decisions. Review of Resident 27's MDS assessment dated [DATE], showed a BIMS score of 11 (moderately impaired cognition). Review of Resident 27's Skilled Nursing assessment dated [DATE], showed Resident 27 was continent of the bowel and bladder. On 11/19/25 at 0944 hours, an interview was conducted with LVN 1. LVN 1 was made aware of the placement of Resident 27's call light which was located by her left upper thigh, covered with blanket and bed cover sheet. LVN 1 stated the call light should be visible and within the resident's reach. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 3 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation review, the facility failed to ensure seven of seven residents (final sampled Residents 4, 45, and 68; and nonsampled Residents 28, 35, 39, and 62) present in the residents' council meeting were provided with the required information. * Residents 4, 28, 35, 39, 45, 62, and 68 were not informed on how to contact the local State agency. This failure posed the risk of the residents not being able to file a complaint directly to the local State Agency.Findings: On 11/20/25 at 1000 hours, a residents' council meeting was held with a total of seven residents. When asked if they knew how to contact their local State agency if they needed to file complaints, Residents 4, 28, 35, 39, 45, 62, and 68 stated they did not know how to contact their local State agency. On 11/20/25 at 1100 hours, a concurrent observation, interview, and review of the facility's resident council minutes was conducted with the Activities Director. When asked how she informed the residents about the contact information for the local State agency, the Activities Director stated she showed the residents the Ombudsman poster. The Activities Director stated she assumed when the residents complained to the Ombudsman office, the Ombudsman office could provide the contact information to the local State agency as needed for the residents. 1. Medical record review for Resident 4 was initiated on 11/20/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 10/6/25, showed Resident 4 had the capacity to understand and make decisions. 2. Medical record review for Resident 28 was initiated on 11/20/25. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's H&P examination dated 10/6/25, showed Resident 28 had the capacity to understand and make decisions. 3. Medical record review for Resident 35 was initiated on 11/20/25. Resident 35 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 6/6/25, showed Resident 35 was able to make her needs known. 4. Medical record review for Resident 39 was initiated on 11/20/25. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's H&P examination dated 10/6/25, showed Resident 39 was able to make her needs known. 5. Medical record review for Resident 45 was initiated on 11/20/25. Resident 45 was readmitted to the facility on [DATE]. Review of Resident 45's H&P examination dated 6/6/25, showed Resident 45 was able to make her needs known. 6. Medical record review for Resident 62 was initiated on 11/20/25. Resident 62 was readmitted to the facility on [DATE]. Review of Resident 62's H&P examination dated 11/16/25, showed Resident 62 was able to make her needs known. 7. Medical record review for Resident 68 was initiated on 11/20/25. Resident 68 was readmitted to the facility on [DATE]. Review of Resident 68's H&P examination dated 11/15/25, showed Resident 68 had the capacity to understand and make decisions. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 4 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **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 report an allegation of abuse to the CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials in a timely manner for one of one resident (final sampled resident, Resident 15) reviewed for an abuse allegation. * The facility failed to timely report the allegations of abuse to the CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement after the facility was made aware of an allegation of abuse made by Resident 15 against the facility staff. This failure had the potential for the delay of the alleged abused investigation and the facility to not take prompt and appropriate corrective actions to prevent further abuse.Findings: Review of the facility's P&P titled Abuse Policy and Procedure dated 3/1/24, showed the facility to maintain an environment free of abuse and neglect. Residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Reasonable attempts will be made to protect the residents from abuse perpetrated by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. The P&P defined the verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with in their hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse included but not limited to hitting, slapping, pinching, and kicking. Further review of the P&P showed facility will follow state and federal mandated reporting guideline in long term care facilities. On 11/19/25 at 1002 hours, an interview was conducted with Resident 15. Resident 15 stated on 11/18/25 at around 1900 hours after dinner, a staff member at the facility spoke to her in a rude and disrespectful manner. According to Resident 15, the staff member said, You didn't listen to what I asked you, and also said, Nobody likes you. Resident 15 further alleged the same staff member physically knocked her hand away, which she demonstrated by tapping her own hand. When asked how frequent was this type of interaction occurred, Resident 15 stated it happened multiple times in the past. Resident 15 stated she did not feel good about the way the staff treated her. Resident 15 stated she had not reported the incident to the facility staff. On 11/19/25 at 1025 hours, the above allegation was reported to the Administrator and DON. Medical Record Review for Resident 15 was initiated on 11/19/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 11/4/25, showed Resident 15 could make medical needs known. Review of Resident 15's MDS assessment dated [DATE], showed Resident 15 had moderately impaired cognitive functions and required staff assistance for her activities of daily living. On 11/20/25 at 0930 hours, further review of the medical records for Resident 15 did not show if the above allegation was reported CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials. On 11/20/25 at 0935 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON stated the allegation of abuse of any kind should be reported as soon as possible within two hours to CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials. The DON stated when the above allegation was reported to her and the Administrator, the facility filed a grievance and the facility staff initiated an investigation. When asked if the facility reported the above allegation of abuse to CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials, the DON stated the facility did not report the above allegation of abuse to the local agencies. The DON acknowledged the above allegation was an allegation of verbal and physical abuse and should have been reported within two hours. On 11/21/25 at 1418 hours, an interview was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 5 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator. The Administrator stated he did not believe the above allegation of abuse needed to be reported because Resident 15 had denied the allegation when interviewed by facility staff. The Administrator stated the facility would initiate an internal investigation immediately upon receiving any abuse allegation. However, if the resident denied the allegation during the investigation, the Administrator would not report the incident to CDPH, Ombudsman, or the local law enforcement agency. The Administrator further stated if he were required to report every allegation, regardless of the residents' denial, he would have to report such incidents frequently, as similar allegations would occur regularly within the facility. On 11/21/25 at 1556 hours, CDPH, L&C department received an SOC 341 from the facility. Review of SOC 341 dated 11/21/25, showed according to the reporter, Resident 15 stated someone described as having white skin with ponytail told her, nobody likes you, and tapped her hand. SOC 341 showed the alleged perpetrator description had no access to the victim, the allegation did not involve any serious bodily injury and according to the reporter, Resident 15 stated the incident occurred the previous night (referring to 11/18/25). Further review of the facility's SOC 341 showed the above allegation was reported to CDPH, L&C department approximately two and half days after the facility was made aware of the abuse allegation. On 11/25/25 at 1356 hours, the DON was informed and acknowledged the above findings. Event ID: Facility ID: 555391 If continuation sheet Page 6 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0628 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the necessary transfer/discharge services was completed one of two closed record sampled residents (Resident 58). * The facility failed to ensure the LTC Ombudsman was made aware when Resident 58 was discharged from the facility. This posed the risk of the LTC Ombudsman not being aware of the circumstances should an appeal be filed by the resident or her representative regarding the transfer/discharge, and the risk of the resident or their representative not being aware of their rights prior to the transfer/discharge from the facility.Findings: Medical record review for Resident 58 was initiated on 12/3/25. Resident 58 was admitted to the facility on [DATE], and was transferred to the acute care hospital on 9/21/25. Review of Resident 58's Notice of Transfer/discharge date d 9/21/25, showed Resident 58 was discharged to the acute care hospital, and the box showing a copy was sent to the LTC Ombudsman was checked. On 11/25/25 at 0849 hours, an interview and concurrent medical record review for Resident 58 was conducted with the SSD. When asked about the process of LTC Ombudsman notification when the residents gets transferred or discharges from the facility, the SSD stated she would send a copy of the discharge order via an email to the LTC Ombudsman and would document in a log after she sent the notification to the LTC Ombudsman. When asked to show the email notifying the LTC Ombudsman of Resident 58's transfer to the acute care hospital, the SSD could not locate any email sent to the LTC Ombudsman notifying her about Resident 58's transfer/discharge. On 11/25/25 at 1056 hours, an interview was conducted with the LTC Ombudsman assigned to the facility. The LTC Ombudsman confirmed she did not receive any notification about Resident 58's transfer/discharge to the acute care hospital. Event ID: Facility ID: 555391 If continuation sheet Page 7 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of one final sampled resident reviewed for allegation of abuse (Resident 15). * Resident 15's change in condition evaluation and monitoring was not completed and the physician was not notified of the allegation of the verbal and physical abuse from the staff. This failure had the potential for Resident 15 to not receive the necessary care and services to meet the highest practicable physical, mental, and psychosocial well-being.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status dated 12/26/24, showed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Further review of the P&P showed the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. The nurse will notify the resident's representative if needed and will monitor resident's condition for 72 hours for any changes of condition. Review of the facility's P&P titled Abuse Policy and Procedure dated 3/1/24, under the section Resident Protection showed during and after the investigation, the resident will be protected from the alleged harm. The P&P further showed the staff will closely and frequently supervise the resident. On 11/19/25 at 1002 hours, an interview was conducted with Resident 15. Resident 15 stated on 11/18/25 at around 1900 hours following dinner, a staff member at the facility spoke to her in a rude and disrespectful manner. According to Resident 15, the staff member said, You didn't listen to what I asked you, and also said, Nobody likes you. Resident 15 further alleged that the same staff member physically knocked her hand away, which she demonstrated by tapping her own hand. When asked how frequently this type of interaction occurred, Resident 15 stated that it had happened multiple times in the past. Resident 15 stated she did not feel good about the way staff treated her. Resident 15 stated she had not reported the incident to the facility staff. On 11/19/25 at 1025 hours, the above allegation was reported to the Administrator and DON. Medical Record Review for Resident 15 was initiated on 11/19/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 11/4/25, showed Resident 15 could make medical needs known. Review of Resident 15's MDS assessment dated [DATE], showed Resident 15 had moderately impaired cognitive functions and required staff assistance for her activities of daily living. Further review of Resident 15's medical record failed to show the above allegation of abuse was reported to the physician, and if a change in condition evaluation and assessment was conducted. In addition, the medical record for Resident 15 failed to show if Resident 15 was monitored for any changes in condition. On 11/20/25 at 0935 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the above findings and stated she was not able to find the documentation if a change in condition evaluation was conducted, if the physician was notified, and if a change in condition monitoring of Resident 15 was conducted after the facility was made aware about the allegation of abuse made by Resident 15 against the facility staff. The DON stated the reported allegation made by Resident 15 was a change in condition for Resident 15 and should have been reported to the physician, and a change in condition evaluation and monitoring should have been conducted. The DON acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 8 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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, medical record review, facility document review, and facility P&P review, the facility failed to maintain a safe water temperature levels in two of three rooms (Rooms A and C) tested for the water temperature. * The facility failed to ensure the water temperature in Rooms A and C were between 105-120 degrees Fahrenheit. In addition, when the facility conducted water temperature check, 12 of 27 rooms had sink water temperature of above 120 degrees Fahrenheit. This failure had the potential for the residents to sustain severe burn injury.Findings: Review of the facility's P&P titled Water Temperatures, Safety dated 8/15/23, showed tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Under the section for Policy Interpretation and Implementation showed following:Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F ( 48.88 degrees C), or the maximum allowable temperature per state regulation;- Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; and- Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log; On 11/21/25 at 0853 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated all the residents' rooms in the facility use the same water heater for the hot water supply. The Maintenance Director further stated the closest room from the water heater was Room A, and the farthest room from the water heater was Room C. The water temperature check was conducted showed the following:- Room A had a temperature of 129 degrees Fahrenheit;- Room B had a temperature of 114 degrees Fahrenheit;- Room C had a temperature of 125 degrees Fahrenheit; The Maintenance Director verified the above readings and stated the water temperature should be less than 120 degrees Fahrenheit in the resident care areas to prevent burns to the residents. On 11/21/2 at 1535 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. Review of the Engineering Department Domestic Hot Water Testing Log - Weekly Log Test for November 2025 showed on 11/21/25, a water temperature check was conducted in 27 rooms. The log showed the sink water temperature in 12 of 27 rooms checked were between 122-126 degrees Fahrenheit. The Maintenance Director verified 12 rooms had sink water temperature of above 120 degrees Fahrenheit. On 11/24/25 at 1139 hours, an interview was conducted with Resident 62. Resident 62 stated she was able to use the bathroom without staff assistance. Resident 62 stated on two occasions the water temperature in the sink got too hot, and she had to add cold water. Medical record review for Resident 62 was initiated on 11/24/25. Resident 62 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 62's MDS assessment dated [DATE], showed Resident 62 was cognitively intact. On 11/26/25 at 1030 hours an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 555391 If continuation sheet Page 9 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **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 provide the necessary respiratory care services for one of two final sampled (Resident 4) and one nonsampled resident (Resident 61) reviewed for respiratory care. * The facility failed to administer the oxygen to Resident 4 as per the physician's order. *The facility failed to ensure the oxygen tubing was labeled for Resident 61. These failures had the potential for the residents to not receive the appropriate respiratory care, increased the risks of infection and affect the residents' well-being.Findings: Residents Affected - Few 1. On 11/21/25 at 0809 and 0928 hours, Resident 4 was observed in bed receiving oxygen at a rate of two liters via nasal cannula. Medical record review for Resident 4 was initiated on 11/19/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician's order dated 10/22/23, showed a physician's order to administer continuous oxygen at a rate of three liters per minute via nasal cannula. On 11/21/25 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 verified Resident 4 was receiving oxygen at a rate of two liters per minute. LVN 5 was observed increasing Resident 4's oxygen to three liters per minute. On 11/25/25 at 1317 hours, an interview and concurrent medical record review for Resident 4 was conducted with the DON. The DON stated Resident 4 should have received oxygen at three liters per minute as per the physician's order. The DON stated Resident 4 would sometimes ask for oxygen at two to three liters per minute, but the expectation was for the nurses to clarify the order with the physician. 2. Review of the facility's P&P titled Oxygen Administration dated 11/16/24, showed the facility to provide guidelines for safe oxygen administration. Further, review of the P&P showed to change and date the oxygen tubing, mask or cannula every Sunday by the night shift staff. On 11/19/25 at 0834 hours, Resident 61 was observed lying in his bed. Resident 61 was observed receiving oxygen at a rate of four liters per minute via nasal canula. The oxygen tubing was not observed to be labeled and dated. On 11/19/25 at 0841 hours, an observation and interview was conducted with RN 1. RN 1 verified Resident 61 was receiving oxygen via nasal cannula at four liters per minute and the oxygen tubing was not labelled with the resident's name and date when it was changed. RN 1 stated the facility would change the oxygen tubing every Sunday and the oxygen tubing should be labeled. RN 1 further stated Resident 61's oxygen tubing should have been labeled. Medical record review for Resident 61 was initiated on 11/19/25. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Physician's Order Summary Report showed a physician's order dated 11/18/25, to administer oxygen at four liters per minute via nasal cannula to maintain more than 92% oxygen saturation every shift and to change the oxygen tubing and humidifier every Sunday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 10 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/25/25 at 1356 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. On 11/21/25 at 1120 hours, an interview and record review were conducted with the IP. The IP stated the bagged oxygen tubing should not be on the floor and the incentive spirometer should be bagged in order not to be contaminated. On 11/26/25 at 1000 hours, an interview was conducted with the Administrator and DON. The Administrator and DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 11 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0759 Ensure medication error rates are not 5 percent or greater. 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 pharmaceutical services to ensure the accurate administration of the medications. One of four licensed nurses (LVN 3) observed during the medication administration was found to have two medication errors. The facility's medication error rate was 8%. * LVN 3 failed to administer Resident 2's metformin (antidiabetic medication) 500 mg as ordered by the physician. * LVN 3 failed to administer Resident 53's ferrous sulfate (supplement) 325 mg as ordered by the physician. These failures had the potential to negatively impact the residents' health outcomes.Findings: Review of the facility's dining hours showed the residents' breakfast trays were scheduled to be served at 0715 hours daily. On 11/20/25 at 0905 hours, Resident 2 and 53's rooms were observed for breakfast trays in preparation for medication pass administration. There were no meal trays or any residents observed eating in these rooms. 1. On 11/20/25 at 1000 hours, a medication administration observation for Resident 53 was conducted with LVN 3. LVN 3 was observed administering medications to Resident 53 which included ferrous sulfate (iron supplement) oral tablet 325 mg, one tablet. Medical record review for Resident 53 was initiated on 11/20/25. Resident 53 was admitted to the facility on [DATE]. Review of Resident 53's H&P examination dated 11/4/25, showed Resident 53 had the capacity to make medical decisions. Review of Resident 53's Order Summary Report dated 11/20/25, showed a physician's order dated 11/3/25, for ferrous sulfate 325 mg oral tablet to give one tablet one time a day with breakfast. On 11/20/2025 at 1307 hours, an interview and concurrent medical record review for Resident 53 was conducted with LVN 3. LVN 3 verified Resident 53's order for ferrous sulfate oral tablet 325 mg was to be given one tablet by mouth was not administered with breakfast as ordered by the physician. LVN 3 stated, It should have been administered with breakfast. LVN 3 also verified Resident 53 had his breakfast before at 0800 hours. On 11/24/25 at 1433 hours, an interview and concurrent medical record review for Resident 53 was conducted with the DON. The DON verified the findings. The DON stated, The medication should have been administered with breakfast. The DON further stated, We will be discussing this during QA meeting. On 11/26/25 at 1000 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. The DON stated the nurses wanted to make sure everything went well with survey and unintentionally delayed the medication pass. 2. On 11/20/25 at 1015 hours, a medication administration observation for Resident 2 was conducted with LVN 3. LVN 3 was observed administering medications to Resident 2 which included metformin (medication to treat high blood sugar levels) HCl (hydrochloride) oral tablet 500 mg. Medical record review for Resident 2 was initiated on 11/20/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/6/25, showed Resident 2 could make needs known but could not make medical decisions. Review of Resident 2's Order Summary Report dated 11/20/25, showed a physician's order dated 6/3/25, to give metformin HCL oral tablet 500 mg one tablet by mouth one time a day with breakfast. On 11/20/2025 at 1307 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 3. LVN 3 verified Resident 2's metformin HCL 500 mg was administered after breakfast. LVN 3 stated, It should have been administered with breakfast. LVN 3 verified Resident 2 had breakfast served at 0730 hours. On 11/24/25 at 1433 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON verified the findings. The DON stated, The medication should have been administered with breakfast. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 12 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review, and facility's P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * A tube of Silicone Cream (a protective skin barrier which contains active medication ingredient to retain moisture and promote healing) was observed on the sink counter inside Resident 65's room. * The oral and non-oral medications were stored together inside the medication room. * The refrigerator inside the medication room was not kept clean. * Boxes of medical supplies were observed on the floor inside the medical supply storage room. These failures had the potential to negatively impact the residents' health outcomes.Findings: 1. Review of the facility's P&P titled Medication Labeling and Storage (undated) showed the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 11/19/25 at 0956 hours, during the initial tour of the facility, a tube of Silicone Cream was observed on the sink counter inside Resident 65's room. On 11/19/25 at 0958 hours, an interview and concurrent observation was conducted with CNA 3. CNA 3 verified the Silicone Cream on the sink counter of Resident 65's room. CNA 3 stated she did not know if Resident 65 was using the Silicone Cream. CNA 3 further stated the Silicone Cream should not be there. On 11/19/25 at 1000 hours, RN 1 acknowledged and verified the Silicone cream on the sink counter of Resident 65's room. RN 1 stated, It's just a cream, we have small packets in the treatment cart, but we don't use them, and we don't use this for Resident 65. RN 1 further sated no treatment creams should be at bedside. On 11/20/25, medical record review for Resident 65 was initiated on 11/20/25. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's H&P examination dated 11/12/25, showed Resident 65 had the capacity. Review of Resident 65's Non-Pressure Skin Report dated 11/18/25, did not show an order for the Silicone Cream. On 11/24/25 at 1120 hours, an interview and concurrent medical record review for Resident 65 was conducted with the IP. The IP verified Resident 65's physician's orders and treatment administration record did not show an order for the Silicone Cream. On 11/26/25 at 1000 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Medication Labeling and Storage (undated) showed medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 13 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0761 Level of Harm - Minimal harm or potential for actual harm On 11/21/25 at 0915 hours, an inspection of the medication room and concurrent interview was conducted with LVN 1. The following were observed: Cabinet 1: The first shelf had bisacodyl (laxative) rectal suppositories stored in between the powdered fiber and antacid liquid, with a box of sodium fluoride prescription strength toothpaste. Residents Affected - Few Cabinet 2: The third shelf had fleet enema (saline laxative), fish oil (supplements) soft gels, Florastor (probiotic), Refresh Classic lubricant eyedrops, and ferrous gluconate (iron supplements) tablets, vitamin C and vitamin E oral medications stored together. LVN 1 acknowledged and verified the above findings and stated she just arranged the medications and should have separated the oral and non-oral medications. 3. On 11/21/25 at 0918 hours, an inspection of the medication refrigerator inside the medication room and concurrent interview was conducted with LVN 1. The medication refrigerator was observed with small brownish and blackish particles on the surface of the bottom shelf of the medication refrigerator. LVN 1 verified the findings and stated the nurses cleaned the medication room including the refrigerator, by any shifts daily, and cooperated with each other. LVN 1 further stated, I don't know what happened here, but we will keep this clean. 4. On 11/21/25 at 0922 hours, an inspection of the supply storage room and concurrent interview was conducted with LVN 1. Upon opening the supply storage room, multiple boxes containing Isosource enteral feeding formulas and IV supplies were observed on the floor. LVN 1 verified the findings and stated there should be no boxes on the floor. On 11/26/25 at 1000 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 14 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food items inside the refrigerator used for the residents' food brought in from outside sources were properly labeled, discarded after use-by date, and the bins were cleaned. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the plate conveyor was free of accumulation of dirt. * The facility failed to air-dry the bin containing the scoops. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Census List dated 11/19/25, showed 38 of 38 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Brought by Family/Visitors revised 11/16/24, showed the following:- Food brought by family/visitors that is left with the resident to consume later will be labeled, dated, and stored in the refrigerator when needed; and - The nursing staff will discard perishable food on or before the use by date. On 11/19/25 at 0803 hours, during the initial tour of the facility, an observation of the refrigerator used to store the residents' food brought in from visitors and concurrent interview was conducted with the CDM/Executive Chef, and Dietary Team Lead. The following was observed:- Two bottles of Dr. Pepper were observed unlabeled with resident's name;- A container of rice labeled with resident's name but dated 11/5/25;- An unlabeled popsicle with a use by date of 11/7/25; andTwo lower bins were observed with a dead insect and food debris. The CDM/Executive Chef and Dietary Team Lead verified the above findings. When asked about the food brought from outside by the visitors, the CDM/Executive Chef stated when they received food brought from the visitors, the nurses were to label the food with the resident's name, date when it was received, and to discard food after 72 hours, and the kitchen staff were to clean the refrigerator used to store residents' food brought in from visitors. 2. According to the USDA 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. a. On 11/20/25 at 0918 hours, an observation of the only ice machine used in the SNF and concurrent interview was conducted with the Maintenance Staff and CDM/Executive Chef. When a white paper towel was used to wipe the inside of the ice machine, near the ice chute, black dirt was observed on the paper towel. The Maintenance Staff and CDM/Executive Chef verified the above findings. b. On 11/21/25 at 0928 hours, the plate conveyor was observed with dirt, paper, and straw at the bottom. The CDM/Executive Chef and Dietary Team Lead verified the above findings. 3. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. On 11/21/25 at 0928 hours, a clear bin containing several scoops was observed wet. The CDM/Executive Chef and Dietary Team Lead verified the above findings. Event ID: Facility ID: 555391 If continuation sheet Page 15 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medical record for two of twelve final sampled residents (Residents 7 and 27) were accurate. * The Skilled Nursing Assessments for Residents 7 and 27 failed to show documentation the residents were receiving nebulizer treatment. This failure had the potential for Resident 7 and 27's care needs not being met as the medical record was inaccurate.Findings: 1. Medical record review for Resident 7 was initiated on 11/24/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 9/23/25, showed Resident 7 could make own medical needs known. Review of Resident 7's Order Summary Report dated 11/24/24, showed a physician's order dated 9/23/25, for Ipratropium-Albuterol (medication to treat wheezing, shortness of breath) Inhalation Solution 0.5 - 2.5 (3) mg/3 ml to inhale 3 ml orally via nebulizer (treatment using fine mist that is inhaled into the lungs through a mouthpiece or mask) every six hours as needed for SOB/wheezing. Review of Resident 7's MAR for November 2025 showed Ipratropium- Albuterol Inhalation Solution 0.5 - 2.5 (3) mg/3 ml to inhale 3 ml orally via nebulizer was administered on 11/17, 11/18, 11//21, 11/23, and 11/24/25. Review of Resident 7's Skilled Nursing Assessments under respiratory section dated 11/17/25 at 1207 hours, 11/18/25 at 1330 hours, 11/23/25 at 1856 hours, and 11/24/25 at 1410 hours, did not show documentation Resident 7 was on nebulizer treatment and received the treatment as documented in the MAR. 2. Medical record review for Resident 27 was initiated on 11/21/25. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's H&P examination dated 11/11/25, showed Resident 27 had no capacity to make medical decisions. Review of Resident 27's Order Summary Report dated 11/21/25, showed a physician's order dated 11/17/25, for Ipratropium-Albuterol Inhalation Solution 0.5 - 2.5 (3) mg/3 ml to inhale 3 ml orally via nebulizer every four hours as needed for SOB/wheezing. Review of Resident 27's November 2025 MAR showed Ipratropium-Albuterol Inhalation Solution 0.5 - 2.5 (3) mg/3 ml to inhale 3 ml orally via nebulizer was administered on 11/17, 11/18, 11/19 and 11/23/25. Review of Resident 27's Skilled Nursing Assessments under respiratory section dated 11/19/25 at 2025 hours, 11/20/25 at 2316 hours, and 11/21/25 at 1204 hours, did not show documentation Resident 27 was on nebulizer treatment and received the treatment as documented in the MAR. On 11/24/25 at 1139 hours, an interview and concurrent medical record review for Residents 7 and 27 was conducted with the ADON/MRD. The ADON/MRD stated the medical records staff were conducting chart audits on the skilled charting every other day. The ADON/MRD verified the above findings and stated the respiratory assessments should have been documented accurately. On 11/24/25 at 1433 hours, an interview and concurrent medical record review for Residents 7 and 27 was conducted with the DON. The DON acknowledged the findings. The DON stated Residents 7 and 27 were on nebulizer medications and the Skilled Nursing Assessments should have checked off Yes on the nebulizer treatment. When asked if the nebulizer treatment needed to be checked off only when a nebulizer treatment was administered to the resident, the DON stated it should be checked off when the resident had an order for the nebulizer treatment. On 11/26/25 at 1000 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 555391 If continuation sheet Page 16 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the monthly infection surveillance documents showed if the residents' conditions met the McGeer's Criteria and if the residents listed in the surveillance log had HAI, CAI or suspected infection. * The facility failed to ensure Resident 4 was placed on EBP as per the physician's order. In addition, LVN 5 failed to perform hand hygiene before entering Resident 4's room. These failures had the potential to result in the spread of infection to the facility's vulnerable population. Findings: Residents Affected - Few Review of the facility's P&P titled Infection Control Surveillance Policy (undated) showed the facility to maintain an ongoing, facility-wide surveillance system that identified, tracks, and prevents infections. Infection Preventionist performs daily infection monitoring, maintains surveillance logs and line lists, tracks trends, clusters, and potential outbreak, reports findings to the DON/Administrator and QAPI. Under the section Documentation and Reporting showed to maintain an infection surveillance log and monthly summaries and presents the infection trends and corrective actions at QAPI meetings. Review of the facility's document titled Infection Surveillance Monthly Report for October 2025 showed the total number for the following: - Total infection = 17; - Community Acquired Infection (CAI) = 10 ; and - Healthcare Associated Infection (HAI) = 7. Further review of the Infection Surveillance Monthly Report for October 2025 did not show if the listed residents met the McGeer criteria for infection and were HAI, CAI or suspected of infection. On 11/21/25 at 0941 hours, an interview and record review was conducted with the DSD/IP. The DSD/IP verified the Infection Surveillance Monthly Report for October 2025 did not show if the listed residents were HAI, CAI or suspected infection. The DSD/IP also verified the Infection Surveillance Monthly Report did not show if the residents symptoms met the McGeer criteria for infection. The DSD/IP further stated the facility system would generate the total number of infection, CAI, and HAI based on the data she entered. When asked if she could show the list of the residents who had HAI in October 2025, the DSD/IP was not able to show. On 11/25/25 at 1356 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. According to CDC, assuming contact precautions do not otherwise apply, EBP is recommended for the residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. The EBP involves gown and glove use during high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 17 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0880 Level of Harm - Minimal harm or potential for actual harm toileting, device care or use and wound care. The EBP signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the residents. Medical record review for Resident 4 was initiated on 11/19/25. Resident 4 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 4's Order Summary Report showed the following physician's order: - date 8/26/25, for the left lower extremity post-biopsy wound, cleanse with normal saline, pat dry and apply bacitracin ointment (topical antibiotic) then dry dressing or bandage; and - dated 10/14/25, Resident 4 was on EBP due to wound. a. On 11/19/25 at 0835 hours, 11/20/25 at 0900 hours, 11/21/25 at 0809 and 0928 hours, an observation was conducted in Resident 4's room. Resident 4 was observed in bed and there was no EBP sign observed outside Resident 4's room to indicate the resident was on EBP and for the staff to wear the appropriate PPE when providing care, nor an isolation cart containing the PPEs for the staff to use. On 11/21/25 at 0843 hours, an observation for Resident 4 and concurrent interview was conducted with CNA 1. Resident 4 was observed in bed. There was no sign observed outside the door of Resident 4's room to indicate the resident was on EBP nor an isolation cart inside the room. CNA 1 verified the above findings. CNA 1 stated she did not receive any information on the resident being on EBP, nor did she wear a gown when providing high-contact activities to Resident 4. CNA 1 stated she would know if a resident was on EBP if there was a sign outside the door. b. On 11/21/25 at 0931 hours, LVN 5 was observed going inside Resident 4's room without performing hand hygiene. On 11/21/25 at 0933 hours, an observation for Resident 24 and concurrent interview and medical record review was conducted with LVN 5. LVN 5 verified there was a physician's order to place Resident 4 on EBP. However, LVN 5 verified there was no EBP sign outside Resident 24's door. LVN 5 acknowledged he did not perform hand hygiene when he entered Resident 4's room. LVN 5 stated Resident 24 had a left leg wound from the biopsy but he thought that was done. On 11/21/25 at 1357 hours, an observation for Resident 4 and concurrent interview and medical record review was conducted with the DSD/IP. The DSD/IP verified there was no EBP sign outside the door of Resident 4's room, nor an isolation cart to contain the PPEs inside the room. The DSD/IP stated the residents with wounds were placed on EBP to prevent the spread of the MDROs. The DSD/IP stated an EBP sign was placed outside the door to remind the staff and visitors of the residents on EBP, to wash hands when going in and out of the room, and the staff should wear the proper PPE when providing high-contact activities such as changing linen, showering, hygiene care to the residents on EBP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 18 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotics were not prescribed to one of 12 final sampled residents (Resident 53) and one nonsampled resident (Resident 31) who did not meet McGeer's criteria in the surveillance log. * The facility failed to address the use of antibiotics when Resident 31 and 53's condition did not meet McGeer's criteria for true infection. This failure had the potential for the antibiotics to be used when it was not necessary and could result in the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance dated 11/16/24, showed as a part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. The IP, or designee will review the antibiotic utilization as part of the antibiotic stewardship program and identify specific situation that are not consistent with appropriate use of antibiotics. The therapy may require further review and possible changes if:- The organism is not susceptible to antibiotic chosen;- The organism is susceptible to narrower spectrum antibiotics;- The therapy ordered for prolonged surgical prophylaxis; and - Therapy was started awaiting culture, but culture results and clinical findings do not indicate the continued need for antibiotics. 1. Review of the Infection Surveillance Monthly Report dated October 2025 showed Resident 31's date of admission to the facility was on 10/2/25, the onset of infection was on 10/10/25, and the type of infection showed unknown. Under the section for Sign and Symptoms showed no entry. The document showed Resident 31 received doxycycline (an antibiotic) medication, was seen by the surgeon for abdominal surgery, and had debridement of the necrotic skin of the umbilicus area. Review of Resident 31's Infection Screening Evaluation dated 10/14/25, showed Resident 31 had tenderness on his skin/wound. Further review of the document did not show if the Resident 31's symptoms met McGeer's criteria for true infection. Further review of Resident 31's medical record failed if the facility followed up with the physician when Resident 31's symptoms did not meet the criteria for true infection and Resident 31 was prescribed an antibiotic. 2. Review of the Infection Surveillance Monthly Report dated October 2025 showed Resident 53's admission date was on 11/3/25, the infection onset date was on 9/17/25, with no specific symptoms and Resident 53 was prescribed with vancomycin HCL ( antibiotic) Oral capsule 125 mg medication. Under the section for Comments showed Resident 53 was admitted to the facility with the antibiotic course, per Resident 31 he had been taking the antibiotic due to reoccurring clostridium difficile (bacterium that causes an infection of the colon) and was used for prophylaxis only. The medical doctor was notified and agreed to continue course of antibiotics with no end date. The Comment section further showed Resident 31 had no signs and symptoms of the clostridium difficile. Review of Resident 53's infection Screening Evaluation dated 11/3/25, showed Resident 31 had a current diagnosis of infection but had no signs and symptoms of infection. Further review of the document did not show if Resident 53's infection met McGeer's criteria for true infection. Further review of the medical records for Resident 53 did not show if the physician was notified when Resident 31's infection did not meet the criteria for true infection and was prescribed the vancomycin HCL antibiotic. On 11/21/25 at 0941 hours, an interview and concurrent medical record review for Residents 31 and 53 was conducted with DSD/IP. The DSD/IP verified the above findings and stated Resident 31 did not meet the criteria for true infection. The DSD/IP stated Resident 31 was on doxycycline antibiotic prophylactically after the debridement of her necrotic skin in the umbilicus area. However, the DSD/IP was not able to show if the physician follow up was done regarding Resident 31's symptom not meeting the criteria for true infection and if the physician still wanted to continue the antibiotic. The DSD/IP stated Resident 53 was readmitted with vancomycin Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 19 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0881 Level of Harm - Minimal harm or potential for actual harm antibiotic and the resident did not have any symptoms of the clostridium difficile. The DSD/IP verified Resident 53 ‘s infection did not meet the criteria for true infection. The DSD/IP verified there was no documentation if the physician was notified regarding Resident 53's infection not meeting the criteria for true infection and Resident 31 was prescribed the vancomycin antibiotic. On 11/25/25 at 1356 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 20 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure the education on the risks and benefits of the vaccinations were reviewed with the resident and/or resident representative for eight of 11 residents (Residents 5, 6, 7, 27, 39, 49, 51 and 54) reviewed for immunization. * The facility failed to ensure Residents 5, 27, 49, 51, and 54 were provided education on the risk and benefits when the residents declined pneumococcal vaccination. * The facility failed to ensure Residents 6 and 39 and/or their representative was offered the pneumococcal vaccine and were provided with education on the risk and benefits of pneumococcal vaccination. * The facility failed to ensure Resident 7 received education on the risk and benefits when resident declined the influenza vaccination. These failures had the potential for the residents and/or their representatives not being informed of influenza and pneumococcal vaccine, the benefits and risks of influenza and pneumococcal vaccination to make an informed decision.Findings: Residents Affected - Few Review of the facility P&P titled Immunization dated 11/16/24, showed the facility is to offer Influenza, Pneumococcal and COVD-19 Vaccine to residents and staff, in accordance with CDC, CDPH, CAL-OSHA regulations and recommendations to reduce mortality and morbidity. Under the section procedure showed facility will offer Influenza, Pneumococcal, and COVID- 19 vaccines to residents' staff as scheduled and as needed. Further review of the P&P showed the residents and staff will be informed regarding the risk and benefits and potential side effects associated with the vaccine. 1. Medical record review for Resident 27 was initiated on 11/19/25. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's CAIR2 report dated 11/7/25, did not show if Resident 27 received a pneumococcal vaccination. Review of Resident 27's Pneumococcal Immunization Informed Consent dated 11/7/25, showed Resident 27 declined the pneumococcal vaccination. The section for the Reason showed already received. The Informed Consent did not show if the risk and benefits of the pneumococcal vaccination was explained to the Resident 27 and/or their representative, when Resident 27 declined the pneumococcal vaccination. Further review of the medical records for Resident 27 did not show the pneumococcal vaccination information Resident 27 received as indicated in the informed consent form and if Resident 27 and/or their representative were educated on the risk and benefits of the pneumococcal vaccination for the resident to make informed decision. 2. Medical record review for Resident 54 was initiated on 11/21/25. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's CAIR 2 reports dated 10/20/25, did not show if Resident 54 received a pneumococcal vaccination. Review of Resident 54's Pneumococcal Immunization Informed Consent dated 10/23/25, showed Resident 54 declined the pneumococcal vaccination. The section for Reason showed refused. The Informed Consent did not show if the risk and benefits of the pneumococcal vaccination was explained to Resident 54 and/or their representative, when Resident 54 declined the pneumococcal vaccination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 21 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the medical records for Resident 54 did not show if Resident 54 and/or their representative were educated on the risk and benefits of pneumococcal vaccination for the resident to make the informed decision. 3. Medical record review for Resident 7 was initiated on 11/21/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 9/23/25, showed Resident 7 could make own medical needs known. Review of Resident 7's CAIR2 reports did not show if Resident 7 received an influenza vaccination for the flu season for the year 2025/2026. Review of Resident 7's Influenza Immunization Informed Consent for the year 2025 to 2026 dated 9/23/25, showed the influenza vaccine was declined by the resident representative of Resident 7. Further review of the medical records for Resident 7 failed to show if risk and benefits of influenza vaccine was explained to Resident 7 and/or their representative, when Resident 7's representative refused the influenza vaccine for Resident 7. On 11/25/25 at 1059 hours, an interview and concurrent medical record review for Resident 7, 27, and 54 was conducted with the DSD/IP. The DSD/IP verified above findings and stated facility offered the vaccination; however, the DSD/IP was not able to show the documentation if Residents 27 and 54 and/or their representative were educated on the risk and benefits of the pneumococcal vaccination when Residents 27 and 54 declined the pneumococcal vaccination. In addition, the DSD/IP was not able to show documentation if Resident 7 and/or the representative were educated on the risk and benefits of the influenza vaccination when Resident 7's representative declined the vaccination for Resident 7. On 11/25/25 at 1356 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 6 was initiated on 11/19/25. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's medical record did not show a pneumococcal consent form nor documentation to show if Resident 6 or her representatives were offered the pneumococcal vaccine and provided with education related to the pneumococcal immunization to include its benefits and potential side effects. 5. Medical record review for Resident 39 was initiated on 11/19/25. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's medical record did not show a pneumococcal consent form nor documentation to show if Resident 39 or her representatives were offered the pneumococcal vaccine and provided with education related to pneumococcal immunization to include its benefits and potential side effects. On 11/21/25 at 1417 hours, an interview was conducted with Residents 6 and 39. When asked about the pneumococcal vaccine, Residents 6 and 39 both stated, nobody talked to us about any vaccine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 22 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/26/25 at 0807 hours, an interview and concurrent medical record review for Residents 6 and 9 was conducted with the DSD/IP. The DSD/IP verified there was no pneumococcal consent form nor documentation to show if Residents 6 and 39 or their representatives were offered the pneumococcal vaccine and provided with education related to the pneumococcal immunization to include its benefits and potential side effects. When asked about the residents' pneumococcal immunizations, the DSD/IP stated the pneumococcal vaccine was always offered to the residents; however, she did not document when she offered the pneumococcal vaccine and when she provided the education regarding the risks and benefits of the pneumococcal vaccine. 6. Medical record review for Resident 49 was initiated on 11/19/25. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's H&P evaluation dated 10/28/25, showed Resident 49 had the capacity to make medical decisions. Review of Resident 49's Pneumococcal Immunization Informed Consent form dated 10/27/25, showed Resident 49 declined to have the pneumococcal vaccination. Further review of the form failed to show a documentation if the education regarding the risks and benefits of the vaccine were explained to Resident 49. On 11/21/25, at 1400 hours, an interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP verified Resident 49 declined the pneumococcal vaccine. When asked to show a documentation when the risks and benefits of the vaccine were explained to Resident 49, the DSD/IP stated she did not document this information 7. Medical record review for Resident 5 was conducted on 11/19/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 4/22/25, the section for Decision Making Capabilities showed He is capable, independent. Review of Resident 5's Pneumococcal Immunization Informed Consent form dated 4/18/25, showed Resident 5 declined to have the pneumococcal vaccination. Further review of the form failed to show a documentation if the education regarding the risks and benefits of the vaccine were explained to Resident 5. On 11/21/25, at 1400 hours, an interview and concurrent record review was conducted with the DSD/IP. The DSD/Infection verified Resident 5 declined the pneumococcal vaccine. When asked to show a documentation when the risks and benefits of the vaccine were explained to Resident 5, the DSD/IP stated she did not document this information. 8. Medical record review for Resident 51 was conducted on 11/19/25. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Resident 51's H&P evaluation dated 1/3/25, showed Resident 51 had no capacity to make medical decisions. Review of Resident 51's Covid/Covid Booster Immunization Informed Consent form dated 9/24/25, showed Resident 5's responsible party had declined for Resident 51 to have the Covid/Covid booster (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 23 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete vaccination. Further review of the form failed to show a documentation if the education regarding the risks and benefits of the vaccine were explained to Resident 51's responsible party. On 11/21/25, at 1400 hours, concurrent interview and record review was conducted with the DSD/IP. The DSD/IP verified Resident 51's responsible party declined for Resident 51 to have a Covid/Covid Booster vaccine. When asked to show a documentation when the risks and benefits of the vaccine were explained to Resident 51's responsible party, the DSD/IP stated she did not document this information. Event ID: Facility ID: 555391 If continuation sheet Page 24 of 25 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 11 Residents (final sampled residents, Residents 7 and 27) reviewed for immunization were offered the COVID-19 seasonal vaccine. This failure posed the residents at risk for increased risk for infection and transmission of COVID-19.Findings: Review of the facility's P&P titled Immunization dated 11/16/24, showed the facility is to offer Influenza, Pneumococcal and COVD-19 Vaccine to residents and staff, in accordance with CDC, CDPH, CAL-OSHA regulations, and recommendations to reduce mortality and morbidity. Under the section procedure showed facility will offer Influenza, Pneumococcal and COVID- 19 vaccines to residents, staff, as scheduled and as needed. Further review of the P&P showed the residents and staff will be informed regarding the risk and benefits and potential side effects associated with the vaccine. 1. Medical record review for Resident 7 was initiated on 11/21/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 9/23/25, showed Resident 7 could make own medical needs known. Review of Resident 7's CAIR2 (California Immunization Registry) report did not show if Resident 7 received COVID-19 seasonal vaccine for 2024/25. Further review of Resident 7's medical record failed to show if Resident 7 was offered the updated COVID-19 booster dose for 2024/25. 2. Medical record review for Resident 27 was initiated on 11/19/25. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's H&P examination dated 11/11/25, showed Resident 27 had no capacity to make medical decision. Review of Resident 27's CAIR2 report dated 11/7/25, did not show if Resident 27 received COVID-19 seasonal vaccine for 2024/2025. Further review of Resident 27's medical record failed to show if Resident 27 was offered the updated COVID-19 2 seasonal vaccine for 2024/2025. On 11/25/25 at 1059 hours, an interview and concurrent medical record review for Residents 7 and 27 was conducted with the IP/DSD. The IP/DSD verified the above findings and stated the facility did not offer the COVID-19 seasonal vaccine for 2024/2025 to Residents 7 and 27. The IP/DSD stated she should have offered COVID-19 seasonal vaccine to Residents 7 and 27. On 11/25/25 at 1356 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555391 If continuation sheet Page 25 of 25