Health inspection·April 21, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of the Order Summary Report showed an order dated 4/20/23, to use CPAP at bedtime for sleep apnea and to clean CPAP machine and mask as per the manufacturer's instructions every week. Review of the MAR dated April 2023 failed to show documented evidence for Resident 38's CPAP administration and cleaning. Residents Affected - Few On 4/18/23 at 0902 hours, an observation and concurrent interview was conducted with Resident 38. During the initial tour of the facility, a CPAP machine was observed at Resident 38's bedside with mask inside the drawer without a bag. Resident 38 stated the CPAP machine was her own personal machine and was brought from home. Resident 38 stated the CPAP machine was cleaned once a week at home and it had not been cleaned since she was admitted to the facility. On 4/20/23 at 0715 hours, a follow-up observation and concurrent interview was conducted with Resident 38. Resident 38's CPAP machine was observed at the bedside with mask inside the top drawer without a bag. Resident 38's top drawer was observed to have the bed remote control, papers, and unopened straws. Resident 38 stated she stored the CPAP mask inside her drawer with no bag. On 4/20/23 at 0724 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 38 used the CPAP machine. CNA 1 further stated the CPAP mask should be stored in a plastic bag for infection control purposes. On 4/20/23 at 0734 hours, an observation, concurrent interview, and medical record review was conducted with the DSD/IP. The DSD/IP verified and acknowledged the above findings. The DSD/IP stated the CPAP machine should have a physician's order and the CPAP mask should be stored in a sanitary manner. 2. Review of the facility's P&P titled Oxygen Administration revised October 2010 showed it is the facility's policy to provide guidelines for safe oxygen administration. The P&P also showed to verify if there is a physician's order and to review the physician's orders or facility protocol for oxygen administration. Review of Resident 39's medical record was initiated on 4/18/23. Resident 39 was admitted to the facility on [DATE], and readmitted on [DATE]. On 4/18/23 at 0816 and 1104 hours, an observation was conducted with Resident 39. Resident 39 was observed lying in bed using a nasal cannula connected to an oxygen concentrator machine at 2.5 liters per minute. Review of the MAR dated April 2023 showed an order dated 1/31/23, to administer continuous oxygen at 4 liters per minute via nasal cannula every shift. On 4/18/23 at 1106 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated Resident 39 was on continuous oxygen therapy. LVN 2 verified and acknowledged the above findings. LVN 2 further stated the physician's order for oxygen was at 4 liters per minute and it should be followed. On 4/21/23 at 1319 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 2 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 3. Review of the facility's P&P titled Oxygen Management revised 2/12/22, showed the humidifiers should be dated, timed, and initialed when used. The humidifier should be changed every seven days. On 4/18/23 at 0902 hours, Resident 23 was observed with a nebulizer machine at bedside. Resident 23's nebulizer mask was observed inside Resident 23's bedside drawer. Residents Affected - Few On 4/18/23 at 1113 hours, an observation and concurrent interview was conducted with LVN 1. When LVN 1 took Resident 23's nebulizer mask out of the bedside drawer, Resident 23's nebulizer mask was observed undated and not stored inside a plastic bag. LVN 1 stated it should have been dated and stored in a plastic bag when not in use. Medical record review for Resident 23 was initiated on 4/18/23. Resident 23 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 23's Order Summary Report showed a physician's order dated 4/15/23, to administer ipratropium-albuterol solution (breathing treatment) 0.5-2.5 mg/3 ml inhale orally every four hours as needed for SOB or wheezing via nebulizer. Review of Resident 23's MAR for April 2023, showed Resident 23 received ipratropium-albuterol solution 0.5-2.5 mg/3 ml every six hours for SOB/wheezing for two days via nebulizer on the following dates and times: - 4/15/23 at 1200 and 1800 hours; - 4/16/23 at 0000, 0600, 1200, and 1800 hours; and - 4/17/23 at 0000 and 0600 hours. On 4/21/23 at 0955 hours, an interview was conducted with the DSD/IP. When asked regarding Resident 23's nebulizer supplies, the DSD/IP stated it should be dated and stored in a plastic bag due to risk of contamination and infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 3 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 16 final sampled residents (Resident 31) remained free from accident hazards related to the use of elevated side rails. * The facility failed to ensure the physician's order was obtained and the care plan problem was developed prior to the use of side rails for Resident 31. This had the potential to put the resident at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. On 4/18/23 at 0923 hours, during the initial tour of the facility, Resident 31 was observed lying in bed with ½ (half)right side rail and ¼ (quarter) side rail elevated. On 4/18/23 at 0930 hours, a follow-up interview was conducted with Resident 31. Resident 31 was observed lying in bed with ½ right side rail and ¼ side rail elevated. Resident 31 stated she used the side rails to reposition herself. Medical record review for Resident 31 was initiated on 4/18/23. Resident 31 was readmitted to the facility on [DATE]. Review of Resident 31's MDS dated [DATE], showed Resident 31 was cognitively intact and required extensive assistance with bed mobility from one-staff assistance. Review of Resident 31's Entrapment Risk Evaluation for Bedrails dated 10/14/22, showed bedrails were considered for bed mobility and transfer to promote independence used as enabler, and resident's request for sense of security. The evaluation, under the hazards and risks section, showed Resident 31 had a bed mobility problem and required extensive assist. Review of Resident 31's medical record did not show a physician's order for the use of the side rails. Review of the plan of care did not show a care plan problem to address the use of the side rails. On 4/19/23 at 0934 and 1413 hours, and 4/20/23 at 0808 hours, Resident 31 was observed lying in bed with ½ right side rail and ¼ side rail elevated. On 4/19/23 at 1642 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated an assessment would be done by the IDT to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 4 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm determine if the side rails were appropriate for the resident, and if deemed appropriate, an assessment for entrapment would be conducted, and a consent would be obtained. The DON also stated a physician's order would be obtained prior to the use of side rails, and a care plan problem would be initiated to address the use of side rails. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 5 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 16 final sampled residents (Resident 41). * Resident 41's lorazepam (antianxiety medication) Controlled or Antibiotic Drug Record did not match Resident 41's MAR. LVN 1 did not document the lorazepam administration in the resident's MAR. This failure posed the risk for diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Substances revised April 2019 showed under the section for Administration, the nurse administering the medication is responsible for recording the time of administration. On 4/19/23 at 1501 hours, review of Resident 41's Controlled or Antibiotic Drug Record and MAR was conducted with LVN 2. Review of Resident 41's lorazepam Controlled or Antibiotic Drug Record showed Resident 41 was administered lorazepam 0.5 mg tablet on 1/13/23 at 1050 hours. Review of Resident 41's January 2023 MAR failed to show documentation of lorazepam administration on 1/13/23 at 1050 hours. LVN 2 acknowledged Resident 41's lorazepam Controlled or Antibiotic Drug Record did not match with Resident 41's MAR for January 2023. Medical record review for Resident 41 was initiated on 4/19/23. Resident 41 was admitted to the facility 12/16/22, and readmitted on [DATE]. Review of Resident 41's Order Summary Report showed a physician's order dated 1/13/23, to administer Ativan oral tablet (lorazepam) 0.5 mg by mouth every eight hours as needed for anxiety for 14 days manifested by verbalization of feeling anxious. On 4/20/23 at 0927 hours, an interview and concurrent review of Resident 41's lorazepam Controlled or Antibiotic Drug Record and MAR was conducted with the DON. The DON acknowledged the above findings. The DON stated she would verify who was the LVN that signed the Controlled or Antibiotic Drug Record. On 4/20/23 at 1303 hours, a follow-up interview was conducted with the DON. The DON stated Resident 41's lorazepam should have been documented in the MAR for accuracy. On 4/20/23 at 1308 hours, an interview and concurrent review for Resident 41's Controlled or Antibiotic Drug Record and MAR was conducted with LVN 1. LVN 1 verified and acknowledged the above findings. LVN 1 further stated he forgot to document in Resident 41's MAR when he administered the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 6 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to discard outdated sterile dressing kit tray found in the intravenous cart (Medication Cart B). This posed the risk for this cleaning wound supplies lose their sterility making them unsafe to use. * The facility failed to ensure the oral medications were stored separately from externally used medications and failed to ensure the Sani wipes were stored separately from the medications found in Medication Cart A. This posed the risk for cross-contamination of the medications. * The facility failed to label three bottles of medications for one nonsampled resident (Resident 20) and failed to dispose of the discontinued medication for one nonsampled resident who had been discharged (Resident 459) from the facility. These failures posed the risk of medication errors. * The facility failed to disposed of the expired antibiotic ointment and glucose gel tubes found in Med room [ROOM NUMBER], creating the risk of medication errors of using the expired medications. Findings: Review of the facility's P&P Storage and Expiration of Medications, Biological, Syringes and Needles revised 5/1/07, showed the facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals. Topicals (external) use medications or other medications should be stored separately from oral medications. When infection control issues may be a consideration, the facility should ensure that test reagents, germicides, disinfectants, and other household substances are stored separately from medications. The facility should ensure that medication and biologicals have not been retained longer than recommended by manufacturer or supplier guidelines. 1. On 4/19/23 at 1104 hours, an inspection of Medication Cart B and concurrent interview was conducted with RN 1. A sterile wound dressing change tray kit with an expiration date of 2/18/23, was observed, and RN 1 verified the findings. 2. On 4/19/23 at 1451 hours, an inspection of Medication cart A was conducted with LVN 2. The following was observed: - one hydrocortisone (relives inflammation) suppository 25 mg, diclofenac sodium (relives inflammation) topical gel 1%, ondansetron ODT UD (prevents nausea and vomiting) 8 mg tablet, and a pair of scissors were stored in the same compartment. - Lidoderm 5% patches (relives pain) were stored in the same compartment with one tub of cholestyramine 4 gram powder (treats high cholesterol), administered orally. - Lidoderm patch 5% mixed with a can of food and beverage thickener, vitamin D3 5000 units with COQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 7 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 (supplements) 100 mg tablet, one tub of Sani cloth plus (disinfection wipes), bisacodyl suppository (treats constipation) 10 mg, acetaminophen suppository (fever reducer) 650 mg, proheal liquid protein collagen + whey protein formula liquid (supplement), lactulose solutions (laxative) 10 mg/15 ml, blood pressure apparatus, stethoscope, and a bottle for drug disposal were stored in the same compartment LVN 2 stated the bottle for drug disposal was used for the medications refused by the residents and kept for 15 to 30 days, then disposed to the pharmacy bin in the medication room. LVN 2 verified the above findings. On 4/20/23 at 0919 hours, the DON further verified the internal medications should not be mixed with the external and biologicals, and expired medication or dressing kits should be discarded. 3. During an inspection of Med room [ROOM NUMBER] and concurrent interview with RN 2 and LVN 2 on 4/19/23 at 1427 hours, the following was identified: - one box of enoxaparin sodium (blood thinner medicine) 40 mg/0.4 ml syringes, unopened and labeled with Resident 459's name; - one opened box of enoxaparin sodium 40 mg/0.4 ml with no label of the resident's name; - two bottles of Qunol turmeric 500 mg (supplement) with no label of the resident's name; - one bottle of Nutrivein Liposomal vitamin C 1650 mg (supplement) with no label of the resident's name. LVN 2 stated Qunol turmeric and Nutrivein Liposomal vitamin C belonged to Resident 20. LVN 2 was asked how a staff could verify the turmeric and liposomal vitamin C belonged to Resident 20 since there were no labels of Resident 20's name on the bottles. LVN 2 replied they only put the label of the resident's name after opening the bottles. LVN 2 also stated Resident 459 was discharged from the facility with no return anticipated, and they kept the discharged resident's medicines until they were picked up by the resident or family. * Review of Resident 20's medical record was initiated on 4/19/23. Review of the current physician's orders showed an order dated 1/16/23, to administer Turmeric capsule 1000 mg by mouth two times a day for supplement and Liposomal vitamin C 1650 mg two capsules two times a day. Review of Resident 20's MAR on 4/19/23 showed the turmeric and liposomal vitamin C capsules were administered daily at 0900 and 1700 hours. * Review of Resident 459's medical record was initiated on 4/21/23. Resident 459 was admiitted to the facility on [DATE], and discharged on 1/13/23. Review of Resident 459's physician orders showed an order dated 12/26/22, for enoxaparin sodium solution prefilled syringe 40 mg/0.4 ml and was discontinued on 1/9/23. Resident 459's Discharge summary dated [DATE], did not show the resident's discharge medications included enoxaparin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 8 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 4. Review of the facility's P&P titled Storage and Expiration of Medications, Biologicals, Syringes and Needles dated 1/1/13, showed the facility should destroy the medications and biologicals with incomplete, damaged, or missing labels; ensure the medications and biologicals for expired or discharged residents are stored separately, away from use, or until destroyed; and should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals. Residents Affected - Few Review of the facility's P&P titled Medication Brought to Facility by the Resident/Family/Physician/ Prescriber dated 1/5/17, showed the nonprescription medications must be kept in the original container and with the resident's name. During an inspection of Med room [ROOM NUMBER] and concurrent interview with the CSC on 4/19/23 at 1350 hours, the following was identified: - one tube of Insta-glucose liquid glucose (to treat low blood sugar) with an expiration date of 3/2023 - one tube of Sunmark Double Antibiotic Oinment with an expiration date of 2/2023. The CSC stated she should have discarded the expired medicines and she had missed it. The CSC also stated she checked the medication supplies every month but did not document her tracking of the supplies and expirations of the medications. On 4/19/23 at 1449 hours, an interview was conducted with the DON. The DON stated the medications with no labels were discarded, and the medications of the discharged residents were kept for seven days for the resident or family to get them before disposal. The DON confirmed the drugs for disposal were done on a monthly basis by a company called Mediwaste. Review of the facility's log book for drug disposal showed a signature from Mediwaste on the first of week each month for the months of January to April 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 9 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for residents' food brought in by visitors. In addition, the facility failed to ensure the foods stored in the refrigerator belonged to the residents and not the staff, and expired foods were discarded. * The facility failed to ensure the foods were stored off the floor. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure the plate lowerator (adjustable heated plate dispenser) and resident refrigerator were clean. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the cooking utensils were in good repair. 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 CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/18/23, showed 56 of 57 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised date 4/6/23, showed all products should be inspected for safety and quality and be dated upon receipt, when opened, and when prepared. On 4/18/23 at 0754 hours, an initial tour was conducted in the kitchen and the following was observed: a. In a refrigerator in the kitchen, a container of milk was observed open but was not labeled with an open date. Dietary Aide 1 verified the findings. b. In the pantry area, the following was observed opened but not labeled with an open date: -a box of cornstarch; -a can of bakery release spray; -a container of sea salt; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 10 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 -a pack of brown gravy mix; Level of Harm - Minimal harm or potential for actual harm -a pack of chicken gravy mix; -a pack of hot cereal cream; Residents Affected - Some -a container of ground all spice; -a container of caraway seed; -a container of clear canola salad oil; and -a container of ground cardamom. The [NAME] verified the findings. c. In Refrigerator 2, a container of beef base was observed open and unlabeled with an open date. The CDM verified the findings and stated the food items should have been properly labeled and dated with the received and open dates. 2. Review of the facility's P&P titled Food from Outside Sources dated February 2018 showed perishable food should be sealed and dated with a use-by date and placed in refrigerators. Review of the facility's Employee Handbook issued March 2022, under Break Rooms, showed the employee break rooms are located near the time clocks and are open to employees for all breaks, and all staff are able to put in personal items, such as lunch bags, in the employee breakroom refrigerators on a first come, first serve basis. On 4/18/23 at 1412 hours, an observation of the residents' refrigerator in the Activity Lounge was conducted with the CDM and the Chef de Cuisine, with the Activities Director present. The following was observed: - an unopened bottle of Pepsi, unlabeled and undated; - an unopened bottle of Coca-cola, unlabeled and undated; - two apples, unlabeled and undated; - a bottle of unopened dairy whipped topping, unlabeled and undated; - a bottle of unopened [NAME] sparkling cider, unlabeled and undated; - a box containing four unopened ice pops, labeled with resident name, but undated; - a box of unopened protein bowl microwaveable packaged meal, unlabeled and undated; - a box of unopened enchilada cheese microwaveable packaged meal, unlabeled and undated; - a box of unopened county fried chicken microwaveable packaged meal, unlabeled and undated; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 11 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 - two unopened tubs of ice cream, and several unopened containers of ice cream, unlabeled and undated. Level of Harm - Minimal harm or potential for actual harm On 4/18/23 at 1420 hours, a follow-up interview was conducted with the CDM, Chef de Cuisine, and Activities Director. The CDM stated the dietary staff checked the refrigerator's temperature and cleanliness, and made sure the food items inside the refrigerator were labeled with the residents' name and dates. The CDM stated the tubs and containers of ice cream were from the kitchen and given to the residents during the activities. When asked about the boxes of microwaveable packaged meal, the Activities Director verified these belonged to her. The CDM stated the food items inside the refrigerator should only be used by the residents. Residents Affected - Some 3. According to the USDA Food Code 2022, Section 3-305.11, foods should be stored six inches above the floor. Review of the facility's P&P titled Food Storage revised date 4/6/23, under the Dry Storage section, showed all food should be stored away from the walls, off the floor, and clear of ceiling sprinkles, sewers/waste disposal pipes and vents. On 4/18/23 at 0754 hours, an initial tour was conducted in the kitchen. In the dry storage area, a box containing containers of apple sauce, a box containing buttermilk pancake mix, a box of fancy shredded coconut and a sack of all-purpose flour were observed on the floor. Dietary Aide 1 verified the findings. Dietary Aide 1 stated these food items were on the floor because they did not have enough room in the dry storage area. 4. On 4/19/23 at 0832 hours, an observation and interview was conducted with the Plant Operations Director, Plant Operations Supervisor, and Plant Operations Staff. During the ice machine inspection, a brownish debris was removed with a white paper towel from the ice chute. The Plant Operations Director and Plant Operations Supervisor verified the findings and stated they would clean the ice machine today. 5. According to the USDA Food Code 2022, 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils, the food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. a. On 4/18/23 at 1412 hours, an observation of the residents' refrigerator in the Activity Lounge was observed with an orange liquid spill at the bottom of the freezer, and a brownish substance was observed inside one of the bins in the freezer. The CDM and Chef de Cuisine verified the findings. The CDM stated the dietary staff checked the refrigerator to check the food items inside, and check the temperature of the refrigerator, and make sure the refrigerator was clean. The CDM stated the dietary staff could wipe off any minor liquid spill, and the housekeeping department cleaned the refrigerator. b. On 4/20/23 at 0900 hours, an observation of the plate lowerator was conducted. The plate lowerator was observed with plates. The plate lowerator was observed with dirt and brownish substance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 12 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 inside and on the spring coils. The Chef de Cuisine verified the findings. The Chef de Cuisine stated the dietary staff cleaned the inside and top surfaces of the plate lowerator, but they would have to call the maintenance department to clean the dirt from the spring coils of the plate lowerator. 6. According to the USDA Food Code 2022, 4-501.12, Cutting Surfaces, surfaces such as cutting blocks that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 4/20/23 at 1420 hours, four cutting boards were observed to be heavily marred with knife marks. The CDM and Chef de Cuisine verified the cutting boards needed to be replaced. 7. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/20/23 at 0900 hours, a chipped plate was inside the plate lowerator. The Chef de Cuisine verified the findings. On 4/20/23 at 0930 hours, in the kitchen utensils bin, a plastic serving spoon was observed with a worn-off glaze, and a spatula and a ladle were observed with the plastic handles melted . The CDM and Chef de Cuisine verified the findings. On 4/20/23 at 1420 hours, three rubber spatulas were observed chipped. The CDM and the Chef de Cuisine verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 13 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to implement their Quality Assessment and Assurance (QA&A) plan of action. There was no documentation to show the facility was monitoring the effects of the corrective action plan to identify if they had achieved and sustained the improvement for the repeated deficient practice cited at F695 in accordance with their POC for an abbreviated survey completed on 2/18/20. This had the potential to affect the quality of care for all the residents in the facility. Findings: On 4/21/23 at 1400 hours, an interview and concurrent facility document review was conducted with the Administrator. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 2/18/20, showed a deficient practice cited at F695 related to the CPAP cleaning per the manufacturer's specifications. The POC included the a corrective action for the Health Information Director/Designee to conduct an audit on all CPAP orders to ensure proper placement on the MAR and weekly cleaning were conducted. Any findings will be reported to the QA for three months and/or until 100% compliance achieved. Review of the facility's QA documents failed to show the facility had conducted its corrective action plan for

F695 to audit all CPAP orders to ensure proper placement on the MAR and weekly cleaning performed for three months and/or 100% compliance was achieved. On 4/21/23 at 1420 hours, the Administrator verified the facility documents and stated the Health Information Director/Designee failed to conduct the the corrective action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 14 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. According to the USDA Food Code 2022 Section 4-501.11, equipment shall be maintained in good repair and proper adjustment. Residents Affected - Few a. On 4/18/23 at 1117 hours, an observation of the kitchen and concurrent interview was conducted with the CDM. The chest freezer was observed with a thick ice build-up surrounding the interior of the freezer. The freezer was observed with several tubs of ice cream. The CDM verified the above findings. b. On 4/19/23 at 0830 hours, a follow-up observation of the kitchen and concurrent interview was conducted with the CDM. The interior surface of the microwave was observed corroded. In addition, rust and chipped paint were observed on the interior left side of the microwave. The CDM verified the findings and stated the microwave needed to be replaced. Based on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in the safe operating condition. * The facility failed to ensure two glucometers (a device which measures the amount of sugar in the blood) currently used by two nonsampled residents (Residents 158 and 458) stored in the medication carts were properly calibrated. In addiition, the facility failed to ensure the glucometer monitoring log were completed. These posed the risk for inaccurate blood glucose test results and inappropriate treatments. * The facility failed to ensure there was no ice build up in the chest freezer in the kitchen. In addition, the facility failed to ensure the microwave in the kitchen was free from corrosion, chipped paint, and rust. These failures had the potential for the equipment not functioning in the way they were intended and in turn could cause contamination of the food, leading to foodborne illnesses for the residents who received food from the kitchen. Findings: 1. Review of the [NAME] True Metric Pro Professional Glucose Meter Owner's Manual under Quality Control Testing showed the control test should be performed before using the system for the first time, for practice to ensure testing technique is good, when opening a new vial of test strips, if the results seem unusually high or low, based on patient's condition, if a vial has been left opened or exposed to extreme heat or cold, or humidity, whenever a check on the performance of the system is needed, and if meter damage is suspected (meter was dropped, crushed , wet, etc.) On 4/20/23 at 1312 hours, an inspection of Medication Cart A, interview and concurrent facility document review was conducted with LVN 1. Medication Cart A had three glucometers as follows: - one glucometer with serial no. TP0332331 - one glucometer with serial no. TP0628272 labeled for Resident 158 - one glucometer with serial no. TP0628297 labeled for Resident 458 During the concurrent interview, LVN 1 stated the labeled glucometers with serial numbers TP0628272 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 15 of 16 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 555515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Vista at Morningside 2525 Brea Blvd. Fullerton, CA 92835 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 and TP0628297 were being used for Residents 158 and 458 respectively. Level of Harm - Minimal harm or potential for actual harm Review of the Supreme II Control Solution Record for April 2023 showed the glucometer with serial no. TP0332331 was calibrated from April 1 thru April 20, 2023. The glucometers with serial no. TP0628272 and TP0628297 did not show any calibration. Residents Affected - Few Review of the Routine Check List and Duties for the 11 PM -7 AM shift showed to calibrate and check the controls for glucose monitor and to record the result. On 4/20/23 at 1327 hours, LVN 1 verified the calibration for glucometers should be performed before use for accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555515 If continuation sheet Page 16 of 16