Health inspection·September 20, 2022

F 0550 residents during feeding. 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: 555473 If continuation sheet Page 2 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 assess two of 22 final sampled residents (Residents 55 and 745) for their ability to self-administer the medications. Residents Affected - Few * Resident 745 had a bottle of over-the-counter analgesic cream at the bedside and LVN 6 took it out from the drawer and gave to the resident to self-administer. Resident 745 did not have the assessment and physician's order for the self-administration of medications. * Resident 55 had a packet of A&D ointment (skin protective barrier) at bedside which was provided to self-administer by a facility staff member. Resident 55 did not have the assessment and physician's order to self-administer the A&D ointment. These failures had the potential for poor health outcomes to these residents. Findings: 1. Review of the facility's P&P titled Medications: Self-administration revised 3/1/22, showed it is the facility's policy to provide a safe, effective process for patient self-administration of medication. On 9/13/22 at 0955 hours, an observation and concurrent interview was conducted with Resident 745. Resident 745 was observed lying in bed with a bottle of topical pain reliever on her chest area. Resident 745 stated she used the topical pain reliever on her arms or shoulders for pain. Review of the medical record for Resident 745 was initiated on 9/13/22. Resident 745 was admitted to the facility on [DATE], with a diagnosis of osteoarthritis. Review of Resident 745's Progress Notes dated 9/14/22, showed Resident 745 had the capacity to understand and make decisions. Review of the medical record failed to show documented evidence of the physician's order for the topical pain reliever, nor an assessment was completed for Resident 745 to self-administer the medications. On 9/13/22 at 1010 hours, an observation and concurrent interview was conducted with CNA 6. A bottle of topical pain reliever was observed on top of Resident 745's over bed table. CNA 6 stated Resident 745 used the topical pain reliever on her arms or shoulders. On 9/13/22 at 1034 hours, an interview was conducted with LVN 6. LVN 6 stated she took out the topical pain reliever from Resident 745's drawer because Resident 745 asked for it. LVN 6 further stated the medications should not be at bedside and needed to have a physician's order. On 9/13/22 at 1612 hours, an interview was conducted with RN 4. RN 4 acknowledged and verified Resident 745 was not assessed to safely self-administer medications. 2. Medical Record Review for Resident 55 was initiated on 9/16/22. Resident 55 was admitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 3 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm Review of the Order Summary Report for September 2022 did not show the physician's order for A&D ointment. Review of the plan of care did not show a care plan problem to address Resident 55's ability to self-administer the medications. Residents Affected - Few On 9/15/22 at 1447 hours, an observation and concurrent interview was conducted with Resident 55 in his room. Resident 55 was observed with an open oval scratch mark on his left upper forehead, with ointment. Resident 55 stated he scratched his forehead when he was doing rehab. He put the ointment himself, and the therapist gave him the ointment packets. During the observation, Resident 55 wheeled himself towards his bedside drawer. He pulled out the small packets of A&D ointment. On 9/15/22 at 1504 hours, an interview was conducted with RN 3. RN 3 stated the A&D ointment packets were not supposed to be in Resident 55's bedside drawer. RN3 stated sometimes, the resident asked for the ointment. RN 3 verified there was no order for A&D ointment. On 9/15/22 at 1556 hours, a follow-up interview was conducted with RN 3. RN 3 stated Resident 55 did not have a self- administration assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 4 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 the appropriate care and services related to GT were provied to one of 22 final sampled residents (Resident 46) and one of 11 nonsampled residents (Resident 91). * Resident 91's enteral water bag was unlabeled and undated. * The facility failed to ensure Resident 46's GT syringe was rinsed and dried prior to storing as per the facility's P&P. These failures posed the risk for complications related to the GT for the residents. Findings: 1. Review of the facility's P&P titled Enteral Feeding: Administration by Pump revised date 6/15/22, showed to label administration bag and tubing with the resident's name, room number, date, start time, and flow rate. Medical record review for Resident 91 was initiated on 9/13/22. Resident 91 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed an enteral feed order dated 7/19/22, to flush GT with water 40 milliliters per hour for 20 hours. On 9/13/22 at 0803 and 1002 hours, Resident 91 was observed in bed. An undated and unlabeled enteral bag filled with fluid was observed on Resident 91's enteral pump. On 9/13/22 at 1545 hours, an observation and concurrent interview was conducted with LVN 9 and RN 4. Both of them verified Resident 91's enteral water bag was undated and unlabeled. LVN 9 stated the enteral water bag should have been labeled with Resident 91's name, room number, date, time, and rate. 2. Review of the facility's P&P titled Enteral Feeding: Administration by Pump revised date 6/15/22, showed to rinse and dry syringe, separately store syringe and barrel prior to storing in the labeled and dated plastic bag or container. Medical record review for Resident 46 was initiated on 09/13/22. Resident 46 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 3/4/22, for Glucerna (a meal or snack replacement to help minimize blood sugar spikes) five times a day, 1.5 calories, administer bolus one carton (240 ml) to provide daily a total of 1200 ml/1800 kilocalories. On 09/15/22 at 0947 hours, after administration of Glucerna, LVN 1 was observed holding the GT syringe barrel (the cylindrical part of a syringe that holds fluid) with one hand and used her other hand to insert the GT syringe plunger (the component of the syringe that when depressed pushes the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 5 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few liquid out of the GT syringe barrel). The GT syringe barrel was observed with white liquid residue still inside. LVN 1 proceeded to store the GT syringe in a plastic bag without rinsing, drying, and separately storing the GT syringe as per the facility's P&P. On 09/15/22 at 0957 hours, an interview and concurrent record review of the facility's P&P was conducted with LVN 1. LVN 1 acknowledged she did not rinse and dry the GT syringe. LVN 1 stated she should have rinsed and dried the GT syringe prior to storing it in a plastic bag. On 09/20/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 6 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 and services for two of 22 final sampled residents (Residents 693 and 743). Residents Affected - Few * The facility failed to ensure a physician's order for supplemental oxygen therapy was obtained prior to the oxygen administration for Resident 693. This failure had the potential for Resident 693 receiving unnecessary oxygen. * The facility failed to ensure Resident 743's nasal cannula tubing was dated as per the facility's P&P. This had the potential for increased risks of infection. Findings: 1. Review of the facility's P&P titled Oxygen: Nasal Cannula (medical device to provide supplemental oxygen therapy) revised 6/15/22, showed to verify order. Review of the facility's P&P titled Oxygen: Concentrator revised 6/15/22, showed to verify order. On 9/13/22 at 0759 and 1102 hours, Resident 693 was observed in bed receiving oxygen via nasal cannula at 1.5 liters per minute. Medical record review for Resident 693 was initiated on 9/13/22. Resident 693 was admitted to the facility on [DATE]. Review of the H&P examination dated 9/11/22, showed a diagnosis of pneumonia. Review of the Order Summary Report did not show a physician's order for oxygen administration. Review of the Admission/ readmission Nursing Documentation dated 9/8/22, showed the following: - on oxygen at two liters/minute via nasal cannula - oxygen saturation level: 98% - method: oxygen via nasal - respiratory care needs: oxygen at two liters/minute via nasal cannula/mask Review of the Nursing Documentation Note showed the following entries: - 9/9/22 at 0334 hours, the resident was on oxygen at two liters/minute via nasal cannula. - 9/9/22 at 0800 and 2342 hours, the resident had no shortness of breath, received oxygen via nasal cannula, and had labored breathing with exertion. - 9/10/22 at 2122 hours, 9/11/22 at 2226 hours, and 9/12/22 at 0333 hours, showed the resident had no shortness of breath, received oxygen via nasal cannula, and had labored breathing with exertion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 7 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 Review of Resident 693's plan of care showed a care plan problem revised 9/13/22, addressing Resident 693's risk for respiratory complications with the intervention to administer oxygen as ordered via nasal cannula. On 9/13/22 at 1320 hours, an observation and concurrent interview and medical record review was conducted with LVN 6. When asked why Resident 693 was on supplemental oxygen therapy, LVN 6 stated she would like to check Resident 693's medical record. LVN 6 checked Resident 693's physician's orders and stated Resident 693 had no physician's order for supplemental oxygen therapy. LVN 6 proceeded to Resident 693's room and Resident 693 was observed lying in bed with an oxygen concentrator at bedside and nasal cannula tubing was on Resident 693. LVN 6 acknowledged the oxygen concentrator was set on 1.5 liters per minute and checked Resident 693's oxygen saturation which was at 98%. LVN 6 further stated a physician's order was needed to place the resident on the supplemental oxygen therapy. On 9/20/22 at 0903 hours, an interview with the DON was conducted. The DON verified and acknowledged the above findings. The DON stated there should be a physician's order for the residents to be on the supplemental oxygen therapy.2. Review of the facility's P&P titled Oxygen: Nasal Cannula revised 6/15/22, showed under gather supplies section that nasal cannula labeled with date of initial set-up. Review of Resident 743's medical record was initiated on 9/14/22. Resident 743 was admitted to the facility on [DATE], with a diagnosis of asthma among others. Review of the H&P examination dated 9/11/22, showed Resident 743 had the capacity to understand and make decisions. Review of the Order Summary report dated 9/15/22, showed an order for oxygen at two liters per minute via nasal cannula as needed for shortness of breath and/or to keep oxygen saturation level more than 92%. On 9/13/22 at 0809 hours, during an initial tour of the facility, an observation and concurrent interview was conducted with Resident 743. Resident 743 was observed in bed receiving oxygen at 2 liters per minute via nasal cannula. Resident 743 stated he used the nasal cannula. Resident 743 further stated he needed oxygen to help him breathe better. On 9/13/22 at 0935 hours, an observation was conducted with Resident 743. Resident 743 was observed sitting up in a wheelchair receiving oxygen at 2 liters per minute via nasal cannula. On 9/13/22 at 0938 hours, an observation and concurrent interview was conducted with LVN 6. Resident observed sitting up in a wheelchair receiving oxygen at 2 liters per minute via nasal cannula which was undated. When asked if Resident 743 needed supplemental oxygen, LVN 6 stated Resident 743 was on oxygen as needed. LVN 6 acknowledged and verified the above findings. LVN 6 further stated the nasal cannula tubings should be dated for infection control reasons. On 9/20/22 at 0903 hours, an interview with the DON was conducted. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 8 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 11 nonsampled residents (Resident 78) was administered the medication at the correct time as ordered. * LVN 1 was observed administering the medication to Resident 78 after a meal instead of before meals as ordered. Failure to administer the medication at the right time posed the risk of poor health outcome for this resident. Findings: Review of the facility's P&P titled General Dose Preparation and Medication Administration revised 4/1/22, showed to verify each time a medication is administered at the correct time among others. On 9/15/22 at 0748 hours, a medication pass observation was conducted with LVN 1. Empty meal trays were observed being placed back in the meal carts. LVN 1 was observed administering Insulin Aspart FlexPen (a short acting insulin that to help control blood glucose spikes that happen when eating) 5 units subcutaneously (beneath or under all the layers of skin) to Resident 78. Review of Resident 78's Order Summary Report showed a physician's order dated 4/5/22, to administer Novolog FlexPen Solution Pen-Injector 100 unit per milliliter (Insulin Aspart) inject 5 units subcutaneously before meals related to type 2 diabetes mellitus. On 9/15/22 at 0822 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 78 already had her breakfast at 0730 hours, and acknowledged the Insulin Aspart was administered to the resident after breakfast. LVN 1 stated Resident 78 should have received the Insulin Aspart before meals. On 9/15/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings and stated the breakfast trays were delivered around 0715 to 0730 hours, and the insulin medication should have been given prior to Resident 78's eating breakfast. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 9 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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. 2. Review of the facility's P&P titled LTC Facility's Pharmacy Services and Procedures Manual - Storage and Expiration Dating of Medications, Biologicals revised 7/21/22, showed the facility should ensure the medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. a. On 9/15/22 at 1200 hours, an observation and concurrent interview was conducted with the Central Supply Clerk in the Central Supply Room. Medications were observed in the locked cabinets including three eight ounce bottles of pink bismuth regular strength. The expiration date on the three bottles was 6/22. The bottles were observed in the same area as the non-expired medications. The Central Supply Clerk stated he must have missed those expired medications when he last checked the medications. Based on observation, interview, and facility document review, the facility failed to follow their controlled medication destruction P&P. This failure posed the risk of drug diversion. Findings: Review of the facility's P&P titled Disposal/ Destruction of Expired or Discontinued Medication revised 5/4/22, showed destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record signature of the registered nurse and licensed professional among others. On 9/16/22 at 1451 hours, an interview and concurrent facility document review were conducted with the DON. The DON stated the process for controlled medication destruction was for controlled medications to be destroyed by the DON and Pharmacy Consultant and both parties should sign the controlled medication count sheet when the medications were destroyed. Review of the controlled medication count sheets showed 9 count sheets that were not signed by the DON. The DON acknowledged the controlled medication count sheets were signed by the Pharmacy Consultant only. The DON stated she and the Pharmacy Consultant performed the controlled medication destruction, but she forgot to sign the controlled medication count sheets. The DON verified the above findings and stated the count sheets should have been signed by her upon destruction of the controlled medications. b. On 9/15/22 at 1037 hours, during the inspection of Intravenous Medication Cart with RN 2, one outdated heparin lock flush 50USP (United States Pharmacopeia - a reference of uniform preparations for the most used drugs) units/5ml was observed. The heparin lock flush showed an expiration date of 8/31/22. RN 2 acknowledged the above findings and stated the expired medications should have been removed and discarded from the cart. On 9/15/22 at 1243 hours, a follow-up interview and concurrent medical record review was conducted with RN 2. RN 2 stated the heparin lock flushes were used to flush Resident 492's PICC line. Resident 492's Central Vascular Access Device (CVAD) Physician/Licensed Independent Practitioner (LIP) Order Sheet dated 8/31/22, showed an order for minimum flush/lock/unused lumens, flush with 5 ml of heparin 10units/ml every 12 hours. The Treatment Record for September 2022 showed the PICC non-valved catheter was flushed with 5 ml of heparin every 12 hours and was signed by the staff. RN 2 acknowledged and verified above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 10 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 On 9/20/22 at 0903 hours, an interview was conducted with the DON. The DON acknowledged the above findings and further stated the expired medications should be discarded for safety reasons. 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: 555473 If continuation sheet Page 11 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: Residents Affected - Some * Residents were served the canned sliced peaches instead of peach shortcake as shown on the posted menu. These failures had the potential for the 91 residents receiving food prepared in the kitchen to not meet their nutritional needs which might lead to nutritional related health complications. Findings: Review of the facility's CMS 672 form dated 9/13/22, showed 91 of 108 residents were served food from the kitchen. Review of the facility's P&P titled Menu Substitutions revised 10/27/19, showed the director of dining services or designees revised the day's menu program components (Week-At-A-Glance, Display Menu, Selective Menu, Diet Guide and Production Sheet) to reflect the change. The policy also showed substitutions are communicated to the residents and other department employees, as appropriate. Review of the facility's Diet Guide Sheet for Tuesday (Day 10) Lunch showed all residents were to be served peach shortcake for dessert. Review of the facility's Week-At-A-Glance Week 2 menu showed the residents were to be served peach shortcake at lunch. However, during the observations, the residents were not served peach shortcake as per the diet guide and menu. For example: 1. On 9/13/22 at 1210 hours, an observation and concurrent interview was conducted with RNA 1. Resident 3's meal ticket showed he was to receive a regular dysphagia advanced diet. Review of the facility's Diet Sheet Guide for 9/13/22 showed Resident 3 was to receive one square of peach shortcake in his meal tray; however, Resident 3 was served the canned sliced peaches. RNA 1 verified the finding. 2. On 9/13/22 at 1215 hours, an observation was conducted for Resident 84. Resident 84's meal ticket showed she was to receive a regular dysphagia advanced diet. Review of the facility's Diet Sheet Guide for 9/13/22, showed Resident 84 was to receive one square of peach shortcake in her meal tray; however, Resident 84 was served the canned sliced peaches. 3. On 9/13/22 at 1244 hours, an observation and concurrent interview for Residents 22 and 32. Resident 22 and 32's meal tickets showed they were to receive a regular dysphagia advanced diet. Review of the facility's Diet Sheet Guide for 9/13/22 showed Resident 3 was to receive one square of peach shortcake in his meal tray; however, Resident 3 was served the canned sliced peaches. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 12 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 0803 DON verified the findings. Level of Harm - Minimal harm or potential for actual harm Further review of the facility's posted Week-At-A-Glance Week 2 menu failed to show the peach shortcake was substituted with the sliced canned peaches for lunch service on 9/13/22. Residents Affected - Some On 9/13/22 at 1228 hours, an interview was conducted with the Dietary Manager. The Dietary Manager verified the above findings and stated the facility was not able to serve peach shortcake to any residents and substituted it with canned sliced peaches. The Dietary Manager also verified she did not inform the residents of the change before serving their meals. The Dietary Manager acknowledged the posted menu and diet sheet guide did not reflect the changes made to the residents' lunch meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 13 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to follow the proper sanitation and food storage practices. Residents Affected - Some * The facility failed to ensure the prepared food items were properly dated and labeled. *The facility failed to ensure the resident and staff's personal food items were not stored in the walk-in refrigerator. * The facility failed to ensure the personal belongings were stored away from the kitchen preparation area. * The facility failed to ensure the food items in the resident's refrigerator were properly labeled and dated. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's CMS 672 form dated 9/13/22, showed 91 of 108 residents were served food from the kitchen. 1. During the initial tour of the kitchen on 9/13/22 at 0730 hours, with the Dietary Manager, the following items were found in the walk-in refrigerator: - an undated white paper bag labeled with a resident's room number and last name containing prepared soup; - a box of a staff member's Spanish Serrano ham; - an unlabeled and undated purple container of prepared food; - an unlabeled and undated piece of tortilla wrapped in foil; and - an unlabeled and undated white foam cup with pureed substance. The Dietary Manager verified the above findings. The Dietary Manager stated the resident's prepared food should not be stored in the kitchen, staff personal food items should not be stored in the kitchen, and unlabeled and undated food items should be thrown away. The Dietary Manager also verified the purple container of food and tortilla wrapped in foil were the facility's staff food. 2. According to the USDA Food Code 2017, 6-501.110, personal belongings can contaminate, food, food equipment and food contact surfaces. On 9/19/22 at 0730 hours, an observation of the food preparation area was conducted with the Dietary Manager. A staff's cell phone was observed on top of a blue cooler in the food preparation area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 14 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The Dietary Manager verified the findings and stated the cell phone should not be there. Level of Harm - Minimal harm or potential for actual harm 3. On 9/15/22 at 1432 hours, an observation of the residents' refrigerator was conducted with RN 2. The following items were found unlabeled and/or undated: Residents Affected - Some - a black container of food - a gray plastic bag labeled with a resident's room number containing cheese, fruit, cherry tomatoes and cucumbers - a clear container covered with a paper towel containing slices of watermelon - a white bag with multiple packages of cheese - a clear container with a red top containing soup, unlabeled and undated;- a bag of chips - a bottle of fish sauce RN 2 was asked if she knew who owned any of the food items in the residents' refrigerator. RN 2 stated she did not know if they were the staff or residents' food items. RN 2 verified only the residents' food should be in the refrigerator and the items should be labeled and dated. On 9/19/22 at 1235 hours, an interview was conducted with the RD. The RD acknowledge the above findings. The RD stated food stored in the kitchen should be reserved for the residents only and no prepared resident's food should be in the walk-in refrigerator. The RD added no staff food should be stored in the kitchen. The RD also stated the personal items should be stored away and should not be in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 15 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility P&P review, LVN 1 failed to follow the facility's P&P on hand hygiene practices and infection prevention during contact with two residents (Residents 46 and 78). Residents Affected - Few * LVN 1 did not perform hand hygiene during Resident 78's medication administration. * LVN 1 did not perform hand hygiene before GT medication administration for Resident 46. These failures had the potential to spread infectious organisms to the residents. Findings: Review of the facility's P&P titled General Dose Preparation and Medication Administration revised date 4/1/22, showed prior to preparing or administering medications, authorized and competent facility staff should follow the facility's infection control program (for example handwashing). Review of the facility's P&P titled Hand Hygiene revised date 11/28/17, showed to perform hand hygiene before resident care, after resident care, and after contact with the resident's environment among others. 1. On 9/15/22 at 0812 hours, a medication administration observation was conducted with LVN 1. LVN 1 was observed placing individual medication cups on a medication tray. LVN 1 donned a pair of clean gloves without performing hand hygiene. LVN 1 administered Resident 78's medications. LVN 1 doffed gloves and with one CaviWipes, LVN 1 proceeded to clean the medication tray, top of the medication cart, then the thermometer with the same wipe. On 09/15/22 at 0822 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she did not perform hand hygiene before donning gloves and she used the same CaviWipes wipe to disinfect the medication tray, top of the medication cart, and thermometer. LVN 1 stated hand hygiene was performed before donning gloves to administer medications and after doffing gloves. LVN 1 stated she should have used a different wipe to disinfect the medication tray, medication cart, and thermometer. On 09/15/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings and stated the staff should have performed hand hygiene before and after removal of gloves. Furthermore, the DON stated they had plenty of CaviWipes and the staff should have thrown the dirty wipe and used a new one to clean the other items. 2. On 9/15/22 at 0912 hours, a medication administration observation was conducted with LVN 1. LVN 1 prepared Resident 46's medications for administration. LVN 1 donned a pair of gloves for the GT medication administration and cleaned the stethoscope (a medical instrument used in listening to sounds produced in the heart, lungs or gastrointestinal tract) with alcohol swab. LVN 1 adjusted Resident 46's bed height, pulled the privacy curtain, and touched Resident 46's footboard. Without changing the gloves and performing hand hygiene, LVN 1 proceeded to auscultate Resident 46's bowel sounds, aspirate (to draw by suction) gastric contents, and administer medications. On 09/15/22 at 0929 hours, an interview was conducted with the DON. The DON verified the above findings and stated the staff should have changed gloves after touching other surfaces prior to enteral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 16 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 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 feeding administration. 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: 555473 If continuation sheet Page 17 of 18 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 555473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Gardens Care Center 13075 Blackbird Street Garden Grove, CA 92843 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure the patient care equipment was maintained in a safe operating condition when two of five glucometers were not checked for quality control. This failure put the residents at risk for inaccurate blood sugar readings. Residents Affected - Few Findings: Review of the Assure Platinum Blood Glucose Monitoring System User Instruction Manual showed to use Assure dose control solutions to check if the meter and test strips are working correctly as a system, and ensure you are testing correctly. Perform a control solution test before testing with the Assure Platinum system for the first time, when you open a new bottle of test strips, to check your technique, and each time the batteries are changed. a. On 9/15/22 at 1218 hours, an observation, interview, and concurrent facility document review was conducted with RN 3. The Assure Platinum blood glucose monitor with the serial number 1040-4057618 was observed in Medication Cart A. RN 3 was asked to show documentation of the quality control check using the control solution for the blood glucose monitor machine. Review of the facility's document title Assure Platinum Blood Glucose Monitoring System: Quality Control Record for Medication Cart A dated 9/22 showed the Assure Platinum Meter serial number 1040-4743645. RN 3 was unable to explain why the serial numbers did not match and was unable to show documentation the Assure Platinum Meter in use had the quality control check done. b. On 9/15/22 at 1225 hours, an observation, interview, and concurrent record review was conducted at Medication Cart B with RN 3. The Assure Platinum Blood Glucose Meter was observed in the cart with the serial number 1040-4057623. RN 3 was asked to show documentation of the quality control check for the Assure Platinum Meter in use. Review of the facility's document titled Assure Platinum Blood Glucose Monitoring System: Quality Control Record for Medication Cart B dated 9/22 showed Assure Platinum Meter serial number 1040-4133272. RN 3 was unable to explain why the serial numbers did not match and was unable to show documentation the Assure Platinum Meters in use had the quality control check done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555473 If continuation sheet Page 18 of 18