Health inspection·October 27, 2023

F 0578 death) and it was signed by Resident 16's family members on 5/5/22. Level of Harm - Potential for minimal harm Further review of Resident 16's Physician Order Report for 10/1/23 to 10/31/23, showed a full code was ordered on 5/18/18. Residents Affected - Some On 10/25/23 at 1056 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the medical record and verified the above findings. RN 1 stated he would call the MD to update the physician's order for do not resuscitate. On 10/26/23 at 0945 hours, an interview with the DON was conducted. The DON stated the POLST and physician's order should be the same. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 2 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. Review of the facility's P&P titled Do Not Resuscitate: Withholding and Withdrawing Life Sustaining Treatments and Brain Death, reviewed 8/2023, showed the RN will document the resident's DNR status in their care plan. Medical record review for Resident 23 was initiated on 10/24/23. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Physician Orders For Life-Sustaining Treatment (POLST) dated 7/6/22, showed Resident 23's selected treatment as Do Not Attempt Resuscitation/DNR, and to allow a natural death. Review of Resident 23's comprehensive Resident Care Plan failed to include the resident's DNR status in their plan of care. b. Review of Resident 23's Physician Order Report for October 2023 signed by the physician on 10/1/23, showed an order dated 7/23/23, for two padded side rails to be up while in bed for safety related to seizure activity. Review of Resident 23's comprehensive Resident Care Plan showed the following care plan problems: -An identified concern for at risk for injury was initiated 9/18/20. The approaches included to apply padded side rails as ordered by the physician. -An identified concern for risk for falls was initiated 9/18/20. The approaches included to apply padded side rails as ordered by the physician. -An identified concern for risk of injury related to seizures was initiated 9/18/20. The approaches included to apply padded side rails as ordered by the physician. On 10/24/23 at 0821 hours, Resident 23 was observed laying in their bed with bilateral side rails up. No padding was observed on the bed side rails. On 10/25/23 at 0801 and 1140 hours, Resident 23 was observed laying in their bed with bilateral side rails up. No padding was observed on the bed side rails. On 10/26/23 at 0753 hours, Resident 23 was observed laying in their bed with bilateral side rails up. No padding was observed on the bed side rails. On 10/26/23 at 1432 hours, an observation, interview, and concurrent medical record review were conducted with LVN 1. LVN 1 reviewed Resident 23's physician's order and verified the resident had an order for bilateral padded side rails up for safety related to seizure activity. LVN 1 went to Resident 23's bedside and verified the resident was in bed with bilateral side rails up, and the side rails were not padded. On 10/27/23, an observation, interview, and concurrent medical record review were conducted with RN 2. RN 2 verified Resident 23's care plan showed the padded side rails should be used while in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 3 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the plan of care to reflect the individual needs for one of 14 final sampled residents (Resident 23) and one nonsampled resident (Resident 9). * Resident 9's care plan intervention of padded side rails was not implemented by the facility staff. Residents Affected - Few * Resident 23's DNR code status was not included in the resident's comprehensive care plan. * Resident 23's care plan intervention of padded side rails was not implemented by the facility staff. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Planning revised 8/2010 showed the purpose of care planning is to assure a coordinated and comprehensive written plan is developed based on the resident assessment and instrument and on the individual needs of the Resident. Medical record review for Resident 9 was initiated on 10/24/23. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's Physician Order Report for October 2023 showed an order dated 8/8/23, for a low bed with padded side rails x 2 when in bed for severe involuntary muscular spasm/coughing spasm for safety per family request. Review of Resident 9's Resident Care Plan showed a care plan initiated 6/5/13, for Resident 9's risk for injury due to the use of siderails related to severe neuromuscular spasms. Further review of the care plan showed an approach plan, dated 10/8/21, for padded side rails x 2 while in bed for safety related to severe involuntary muscular spasm/coughing spasm per family's request. During the initial tour of the facility on 10/24/23 at 0830 hours, Resident 9 was observed lying in bed with bilateral side rails. No padding was observed on the side rails. On 10/25/23 at 1410 hours, an observation, interview, and concurrent medical record review were conducted with LVN 1. LVN 1 reviewed Resident 9's physician's order and verified Resident 9 had an order for padded side rails x 2 for involuntary spasms. LVN 1 verified Resident 9's side rails were not padded. LVN 1 stated Resident 9's side rails should be padded due to the potential for injury from spasms. On 10/26/23 at 1139 and 1452 hours, Resident 9 was observed lying in bed with bilateral side rails up. No padding was observed on the side rails. On 10/27/23 at 0825 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 reviewed Resident 9's plan of care for risk for injury related to side rails. LVN 1 verified Resident 9's care plan showed an intervention for padded side rails x 2 while in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 4 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 10/27/23 at 1505 hours, the CEO, DON, and DSD acknowledged the above findings. 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: 555567 If continuation sheet Page 5 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care for one of 14 final sampled residents (Resident 18) was revised to reflect the residents' current care needs and interventions. * Resident 18's care plan for hand mittens was not revised to address the current left hand mitten order. This posed the risk of not providing the resident with individualized and person-centered care. Findings: During the initial tour of the facility on 10/24/23 at 0844 hours, Resident 18 was observed in bed with a left-hand mitten on. On 10/24/23 at 0848 hours, an observation and concurrent interview was conducted with LVN 7. LVN 7 verified Resident 18 had a left-hand mitten on. Medical record review for Resident 18 was initiated on 10/24/23. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's physician's order dated 10/17/23, showed to provide left hand mitten to prevent the resident from pulling out invasive tubing and to release every two hours for 15 minutes for circulation and skin checks. Review of Resident 18's plan of care showed a care plan problem titled Hand Mitten(s) revised on 10/17/23. The interventions showed to continue to apply bilateral hand mittens. On 10/26/23 at 1038 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified the above findings. The IP stated Resident 18's plan of care should have been revised to reflect Resident 18's current physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 6 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for one of final 14 sampled residents (Resident 32). Residents Affected - Few * The facility failed to ensure Resident 32 was turned and repositioned at least every two hours as per the physician's order and plan of care. This failure put Resident 32 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer on the sacrococcygeal (the tailbone) area and MASD (moisture-associated skin damage; inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine). Findings: During initial tour of the facility on 10/24/23 at 0843 hours, Resident 32 was observed in bed lying on his back. Medical record review for Resident 32 was initiated on 10/24/23. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's H&P examination dated 8/29/23, showed an admitting diagnosis of hemorrhagic CVA (stroke) with right hemiparesis (weakness or the inability to move on one side of the body). Review of Resident 32's MDS admission assessment dated [DATE], showed under Section G for functional status, the resident was total dependence with two persons physical assist for bed mobility. Review of Resident 32's Physician Order Report for 10/1/23 to 10/31/23, showed an order dated 8/28/23, to turn and reposition every 2 hours while in bed. Review of Resident 32's care plan showed a care plan problem addressing the risk for development of skin breakdown dated 8/28/23, with the approach plan included the intervention to turn and reposition every two hours and PRN. Review of Resident 32's Weekly Wound Evaluation dated 10/23/23, showed wound on sacrococcygeal area with depth was unable to determine and MASD to perirectal (skin surrounding the rectum) area which are being treated with triad paste (a topical antiseptic cream used to heal wounds and relieve pain) twice a day. On 10/24/23 at 1145 hours, Resident 32 was observed in bed lying on his back. On 10/25/23 at 0808 hours, Resident 32 was observed lying in bed positioned on his back and remained in the same position at 1020 hours. On 10/25/23 at 1047 hours, an interview was conducted with CNA 2. CNA 2 was asked how often she turned and repositioned the resident assigned to her care. CNA 2 stated she usually turned and repositioned the residents every two hours but did not have time to turn and reposition Resident 32 because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 7 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 she was so busy this morning. Level of Harm - Minimal harm or potential for actual harm On 10/26/23 at 1050 hours, an interview was conducted with LVN 5. LVN 5 was asked how he monitored the turning and repositioning of the residents assigned to his care. LVN 5 stated he looked at the CNA documentation. LVN 5 was informed of Resident 32 observed had not been turned and repositioned since this morning. LVN 5 stated he turned the residents if the CNA did not turn the residents. Residents Affected - Few On 10/26/23 at 0944 hours, an interview with the DON was conducted. The DON was asked if the turning schedule posted in the residents' rooms were being followed. The DON stated not usually, it depended on where the resident was previously positioned. The DON further stated the staff tried to turn and reposition the residents timely. Additionally, the charge nurse would remind the CNA to turn the residents if a resident was not turned. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 8 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10/24/23 at 0844 hours, Resident 18 was observed lying in bed with bilateral side rails elevated. Residents Affected - Few On 10/25/23 at 1044 hours, Resident 18 was observed lying in bed with bilateral side rails elevated. On 10/25/23 at 1420 hours, Resident 18 was observed lying in bed with bilateral side rails elevated and left side rail with padding. Medical record review for Resident 18 was initiated on 10/24/23. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's MDS dated [DATE], showed Resident 18 was cognitively impaired and required maximum assistance from two person with bed mobility. The MDS further showed Resident 18 had seizure disorder. Review of Resident 18's physician's order dated 9/19/23, showed Resident 18 was to have a low bed with bilateral padded side rails for safety due to seizure disorder. Review of Resident 18's plan of care showed a care plan problem titled Side Rail created on 1/13/23. The interventions showed to apply bilateral padded side rails for safety due to seizure disorder. On 10/24/23 at 1421 hours, an interview and concurrent medical record review was conducted with LVN 3. Resident 18 was observed with bilateral side rails elevated with padding on the left side rail. LVN 3 verified the observation. LVN 3 stated Resident 18 used the bilateral padded side rails as a seizure precaution. LVN 3 stated both left and right side rails should have been padded as per Resident 18's physician's order. Based on observation, interview, and medical record review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 18) and one nonsampled resident (Resident 9) remained free from accident hazards. * The facility failed to ensure Resident 9's side rails were padded as ordered by the physician and as care planned. * The facility failed to ensure two staff members assisted in obtaining Resident 1's weights. * The facility failed to ensure Resident 18's bilateral side rails were padded as per the resident's physician's order and care plan. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Medical record review for Resident 9 was initiated on 10/24/23. Resident 9 was admitted to the facility on [DATE], readmitted [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 9 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 9's Physician Order Report for October 2023 showed an order dated 8/8/23, for a low bed with padded side rails x 2 when in bed for severe involuntary muscular spasm/coughing spasm for safety per family request. Review of Resident 9's Resident Care Plan showed a care plan problem initiated 6/5/23, addressing Resident 9's risk for injury due to the use of side rails related to severe neuromuscular spasms. Further review of the care plan showed an approach plan dated 10/8/21, for padded side rails x 2 while in bed for safety related to severe involuntary muscular spasm/coughing spasm per the family's request. During initial tour of the facility on 10/24/23 at 0830 hours, Resident 9 was observed lying in bed with bilateral side rails elevated. No padding was observed on the side rails. On 10/25/23 at 1410 hours, an interview and concurrent observation and medical record review were conducted with LVN 1. LVN 1 reviewed Resident 9's physician order and verified Resident 9 had an order for padded side rails x 2 for involuntary spasms. LVN 1 verified Resident 9's side rails were not padded. LVN 1 stated Resident 9's side rails should be padded due to the potential for injury from spasms. On 10/26/23 at 1139 and 1452 hours, Resident 9 was observed lying in bed with bilateral side rails up. No padding was observed on the side rails. On 10/27/23 at 0825 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 reviewed Resident 9's plan of care for risk for injury related to side rails. LVN 1 verified Resident 9's care plan showed an intervention for padded side rails x 2 while in bed. On 10/27/23 at 1505 hours, the CEO, DON, and the DSD were informed and acknowledged the above findings. 2. Medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted the facility on 10/9/96, and readmitted on [DATE]. Review of Resident 1's Physician Order Report: for October 2023 showed the following orders: - dated 11/22/22, to obtain weekly weights for four weeks, then monthly if the weight was stable. - dated 8/8/23, for the resident to be out of bed per nursing, with two persons assisting facing sideways in the Hoyer lift to the recliner or customized wheelchair reclined roughly 20 degrees. Review of Resident 1's quarterly MDS dated [DATE], showed Resident 1 was total dependence with two or more persons physical assist for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The MDS also showed Resident 1 required two or more persons physical assist for transfers (how resident moves between surfaces including two or from: bed chair, wheelchair, standing position). On 10/26/23 at 0755 hours, RNA 1 was observed in Resident 1's room. Resident 1 was observed lying flat in bed with his enteral feeding on hold. RNA 1 stated he was weighing Resident 1. On 10/26/23 at 0802 hours, RNA 1 was observed applying hand splints on Resident 1. Resident 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 10 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressed, and his enteral feeding was infusing. No licensed staff were observed entering the room. RNA 1 verified he put the enteral tube feeding on hold, transferred the resident onto the weight sling, weighed the resident, and restarted the tube feeding. On 10/26/23 at 1025 hours, an interview was conducted with RNA 1. RNA 1 stated the weights were usually done with two staff members. RNA 1 further stated his coworker was on break when he obtained the weight for Resident 1. On 10/27/23 at 0754 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD stated RNAs were responsible for obtaining the resident weights. The DSD stated the residents were turned from side to side to position the sling under the residents. The DSD reviewed Resident 1's quarterly MDS dated [DATE], and stated there should have been two people to assist with obtaining Resident 1's weight for the resident's safety and to prevent potential injury. On 10/27/23 at 1505 hours, the CEO, DON, and DSD were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 11 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 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** 2. Medical record review for Resident 23 was initiated on 10/24/23. Resident 23 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 23's Physician Order Report for October 2023 showed the following: - An order dated 7/11/23, for Vital 1.5 (enteral formula) to run at 60 ml per hour for 20 hours via the G-tube. - An order dated 7/11/23, may use Pivot 1.5 (enteral formula) at 60 ml per hour if Vital 1.5 not available. On 10/24/23 at 0821 hours, Resident 23 was observed laying in bed. A tube feed pump was observed with two Kangaroo brand bags hanging from the feeding pump pole. One bag had tan liquid in it without a label, and the Kangaroo bag's tubing was connected to the tube feeding pump, running at 60 ml per hour. On 10/24/23 at 0835 hours, an interview and concurrent observation were conducted with the DON. The DON observed Resident 23's Kangaroo bags and stated one was the resident's tube feeding and the other was the water flush. When asked what type of feeding formula the bag contained, the DON stated the bag was not labeled to show the contents, and should be. 3. During the initial tour of the facility on 10/24/23 at 0904 hours, Resident 19 was observed lying in bed with head of bed in a flat position with his enteral feeding of Nepro infusing at 80 ml/hr via GT. Medical record review for Resident 19 was initiated on 10/24/23. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 12/2/22, showed Resident 19 had dysphagia (difficulty swallowing) and was on a GT. Review of Resident 19's physician's order dated 12/2/21, showed to HOB at 30 to 45 degrees at all times while feeding was administered. Review of Resident 19's plan of care showed a care plan problem titled Feeding Tubes revised on 5/16/23. The interventions included to elevate HOB 30 to 45 degrees at all times while feeding was administered. On 10/24/23 at 0908 hours, an observation and concurrent interview was conducted with LVN 8. LVN 8 verified Resident 19's HOB was in a flat position while the enteral feeding was on. LVN 8 stated Resident 19's HOB was not elevated properly while his enteral feeding was on. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of G-tube (a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications; gastrostomy tube) for two of 14 final sampled residents (Residents 1 and 23) and one nonsampled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 12 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 resident (Resident 19). Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure the licensed staff managed the G-tube feeding for Resident 1. CNA 1 had put the G-tube feeding on hold to provide incontinence care for Resident 1. In addition, RNA 1 had put the G-tube feeding on hold and resumed G-tube feeding after obtaining Resident 1's weight. Residents Affected - Few * The facility failed to ensure Resident 23's tube feeding bag was labeled with it's contents. * The facility failed to ensure Resident 19's HOB was elevated during enteral feeding to reduce the risk for aspiration. These failures posed the risk for complications related to use of the G-tube for Residents 1, 19, and 23. Findings: Review of the facility's P&P titled Enteral Feeding via G or J tube, Continuous (Pump) revised 1/2011 showed designated team members responsible for the administration and management of enteral feedings are RNs and LVNs. Further review of the P&P showed the head of bed (HOB) should be elevated 30 to 45 degrees during feedings; and RNs and LVNs are responsible for stopping tube feedings when care is being provided and the HOB is flat. Review of the facility's job description for CNAs titled Cert Nursing Asst SA published 4/12/21, showed the CNA is a non-professional who, under the general supervision of a RN, assists in providing direct patient care by performing non-professional nursing duties in a Sub-Acute Unit. Review of the facility's job description for RNAs titled RNA 12hr, published 10/7/23, showed the Restorative Nurse Assistant is a non-professional who, under the general supervision of a RN, assists in providing direct patient care by performing non-professional nursing duties. 1.a. Medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 11/24/22, showed Resident 1 had a G-tube for long-term management. Review of Resident 1's Physician Order Report for October 2023 showed an order dated 11/23/22, to administer Glucerna 1.2 (a type of feeding formula) to run at 53 ml per hour for 20 hours via the G-tube. On 10/25/23 at 1436 hours, an observation and concurrent interview were conducted with CNA 1. CNA 1 was observed providing incontinent care to Resident 1. Resident 1 was observed lying flat in bed. The G-tube feeding was observed to be on hold. CNA 1 was asked if the licensed nurse put the G-tube feeding on hold. CNA 1 stated she put the G-tube feeding on hold. CNA 1 further stated CNAs could put the G-tube feedings on hold but could not resume the feedings. On 10/26/23 at 0930 hours, an interview and concurrent facility P&P review was conducted with the DON. The DON verified the P&P showed licensed staff such as LVNs and RNs are responsible for managing and operating G-tube feedings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 13 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 On 10/27/23 at 0754 hours, an interview was conducted with the DSD. The DSD stated RNAs and CNAs should not touch the G-tube feedings. The DSD further stated only licensed nurses could operate the G-tube feedings, which consisted of putting the G-tube feedings on hold and/or to resume. The DSD verified the above findings. Residents Affected - Few On 10/27/23 at 1505 hours, the CEO, DON, and DSD were informed and acknowledged the above findings. b. Medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 11/24/22, showed Resident 1 had a G-tube for long-term management. Review of Resident 1's Physician Order Report for October 2023 showed an order dated 11/23/22, to administer Glucerna 1.2 (a type of feeding formula) to run at 53 ml per hour for 20 hours via the G-tube. On 10/26/23 at 0755 hours, RNA 1 was observed in Resident 1's room. Resident 1 was observed lying flat in bed. The G tube feeding was observed to be on hold. RNA 1 stated he was weighing Resident 1. On 10/26/23 at 0802 hours, RNA 1 was observed applying hand splints on Resident 1. Resident 1 was observed in bed and his G-tube feeding was infusing. No licensed staff was observed entering the room. RNA 1 verified that he put the G-tube feeding on hold to weigh Resident 1. RNA 1 further stated he restarted the G tube feeding after he weighed Resident 1. When asked who was responsible for putting the G-tube feedings on hold and resuming the G-tube feedings, RNA 1 stated the nurse. On 10/26/23 at 0930 hours, an interview and concurrent facility P&P review was conducted with the DON. The DON verified the P&P showed licensed staff such as LVNs and RNs were responsible for managing and operating G-tube feedings. On 10/27/23 at 0754 hours, an interview was conducted with the DSD. The DSD stated RNAs and CNAs should not touch the G-tube feedings. The DSD further stated only licensed nurses could operate G-tube feedings, which consisted of putting the G-tube feedings on hold and/or to resume. The DSD verified the above findings. On 10/27/23 at 1505 hours, the CEO, DON, and DSD were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 14 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0694 Provide for the safe, appropriate administration of IV fluids 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** 2. Medical record review for Resident 2 was initiated on 10/24/23. Resident 2 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 2's Clinical Summary Report for 10/26/23, showed an order for piperacillin and tazobactam (an antibiotic) 3.375 grams IV three times a day. On 10/24/23 at 0829 hours, Resident 2 was observed in bed with IV fluids and two IV antibiotics hanging on the resident's IV Pump. The piperacillin and tazobactam IV tubing was not labeled with the date when it was hung or to be changed. On 10/24/23 at 0831 hours, an observation and concurrent interview was conducted with the DON. The DON observed Resident 2's piperacillin and tazobactam IV tubing and verified the tubing was not labeled with the date when it was hung or to be changed. The DON stated it should be dated. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for IV therapy (the administration of fluids or medications through an IV catheter) for two of 14 final sampled residents (Residents 1 and 2). * The facility failed to label Residents 1 and 2's IV medication tubing with the date or time when it was hung. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Residents 1 and 2. Findings: Review of the facility's P&P titled Medication - Intravenous Therapy reviewed 9/2023 showed to mark IV tubing with the date hung, nurse's initials, and date to be changed. 1. Medical record review for Resident 1 was initiated on 10/24/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Patient Orders for 10/26/23, showed an order dated 10/24/23, for cefepime (an antibiotic) 2 grams IV every eight hours. On 10/24/23 at 0815 hours, Resident 1 was observed in bed with IV fluids and cefepime hanging on Resident 1's IV pump. The IV tubing connected to the cefepime was not labeled with the date when it was hung or the date to be changed. On 10/24/23 at 0833 hours, an observation and concurrent interview was conducted with the DON. The DON verified Resident 1's cefepime IV tubing was not labeled with the date when it was hung or date to be changed. The DON stated all IV tubing should be labeled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 15 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 for one of 14 final sampled residents (Resident 18) and two nonsampled residents (Residents 6 and 16) with tracheostomy (breathing tube inserted through the neck into the airway to maintain an open airway). Residents Affected - Few * The facility failed to ensure Residents 6 and 18's oxygen flow meters were set to the appropriate liter flow to match their aerosol mist setting as per physician's orders. * The facility failed to ensure the necessary respiratory care provided to Resident 16 was performed by a designated trained or licensed healthcare member. These failures had the potential for these residents to not receive appropriate respiratory care to negatively affect the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen, Cool Aerosol revised 4/2021 showed the administration of aerosol therapy as an aid to bronchial hygiene is to attempt to hydrate dried secretions, maintain the mucous blanket, promote expectoration, and improve the effectiveness of the cough effort. Aerosol therapy is to be used when precise FI02 (a fraction of the amount of oxygen a resident is inhaling produced by an oxygen device such as a nasal cannula or mask) that is required. Under the Procedure section showed to insert flowmeter into the wall unit and set the FI02 and turn the flowmeter to the appropriate liter flow. 1. During the initial tour of the facility on 10/24/23 at 0844 hours, Resident 18 was observed lying in bed connected to a cool aerosol via T-piece (a device used for delivering oxygen through the trachea). Resident 18's cool aerosol adaptor was set at five liters per minute/28% FI02. Resident 18's T-piece was connected to an oxygen wall unit set at eight liters per minute. Medical record review for Resident 18 was initiated on 10/24/23. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 1/14/23, showed Resident 18 had chronic respiratory failure and tracheostomy (a surgical opening in the neck to the windpipe to administer oxygen to the lungs). Review of Resident 18's physician's order dated 1/13/23, showed to provide aerosol mist to the trach via T-piece at 28% FI02. On 10/24/23 at 0942 hours, an observation and concurrent interview was conducted with RN 3. RN 3 verified Resident 18's oxygen flow meter was set at eight liters per minute and cool aerosol adaptor was set at five liters per minute/ 28% FI02. RN 3 was observed changing Resident 18's oxygen flow meter setting to five liters per minute. 2. During the initial tour of the facility on 10/24/23 at 0901 hours, Resident 6 was observed lying in bed connected to a cool aerosol via T-Piece. Resident 6's cool aerosol adaptor was set at five (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 16 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 liters per minute/28% FI02. Resident 6's T-piece was connected to an oxygen wall unit set at four liters per minute. Medical record review for Resident 6 was initiated on 10/24/23. Resident 6 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 6's H&P examination dated 10/26/23, showed Resident 6 had diagnoses including respiratory failure and tracheostomy. Review of Resident 6's physician's order dated 7/12/05, showed to provide aerosol mist to the trach via T-piece at 28% FI02. On 10/24/23 at 0942 hours, an observation and concurrent interview was conducted with RN 3. RN 3 verified Resident 6's oxygen flow meter was set at four liters per minute and cool aerosol adaptor was set at five liters per minute/ 28% FI02. RN 3 stated the oxygen flow meter should be set at five liters per minute to match the nebulizer adaptor setting at 28% FI02/ five liters per minute. On 10/26/23 1423 hours, an interview was conducted with the Respiratory Therapy Manager. The Respiratory Therapy Manager stated the setting for the oxygen wall unit flow meter and the nebulizer adaptor used for the aerosol mist should match. The Respiratory Therapy Manager stated if the physician's order was to provide aerosol mist at 28% FI02/five liters per minute, then the oxygen wall unit flow meter should be set at five liters per minute. 3. Review of facility's P&P titled Nebulizer, In-line Therapy date revised 4/2021 showed in-line aerosol will be considered acceptable when ordered with a topically active medication such as bronchodilator or vasoconstrictor. Designated team members: RN and Respiratory Therapist. Review of the facility's job description for RNA 12 hr. last published 10/7/23, showed the Restorative Nurse Assistant is a non-professional who, under the general supervision of a Registered Nurse, assist in providing direct patient care by performing non-professional nursing duties. Medical record review for Resident 16 was initiated on 10/24/23. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Current Medications showed an order dated 9/25/23, to administer ipratropium bromide (a medication works by relaxing the muscles around the airways so that they open up for a person to breathe more easily.) 0.5 mg/2.5 ml inhalation nebulizer every 4 hours PRN for SOB and wheezing; and an order dated 10/13/23, for ipratropium bromide 0.5 mg/2.5 ml inhalation nebulizer every 6 hours by Respiratory Therapist. On 10/24/23 at 0943 hours, RNA 2 was observed to disconnect the nebulizer medicine cup from the tracheostomy (surgically created hole in windpipe to provide an alternative airway for breathing) line set up for Resident 16 when assisted CNA 2 to transfer Resident 16 to the shower bed. On 10/24/23 at 0955 hours, an interview with RNA 2 was conducted. When asked if he was allowed to disconnect the tracheostomy line set up, he stated he was not supposed to but needed to remove the nebulizer cup because it was an emergency. RNA 2 was asked what the emergency was, he stated he needed to transfer the resident for a shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 17 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/24/23 at 1000 hours, an interview with LVN 2 was conducted. LVN 2 was asked if it was a usual practice for the RNA to disconnect the tracheostomy line set up to remove the nebulizer medicine cup. LVN 2 stated it was not, and RNA 2 should have called the nurse to remove the nebulizer medicine cup. On 10/26/23 at 0944 hours, an interview with the DON was conducted. The DON was asked if an RNA was allowed to disconnect a tracheostomy set up to remove the nebulizer medication cup, the DON stated the RNA was not allowed to disconnect the tracheostomy set up. Event ID: Facility ID: 555567 If continuation sheet Page 18 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 the appropriate and least restrictive measures of the side rail use were attempted for four of 14 final sampled residents (Residents 2, 23, 30 and 31). * Resident 2 and 31's medical records failed to show the outcome of least restrictive attempt prior to side rail use. * Resident 23 and 30's medical records failed to show the outcome of least restrictive attempt prior to side rail use and documentation of recent seizure activity for which the side rails were ordered. These failures had the potential to put the resident at risk of injury including entrapment. Findings: Review of the facility's P&P titled Siderails, Assessment & Use reviewed 8/2023 showed the use of side rails will be determined by the most appropriate, least restrictive type of restraint. 1. Medical record review for Resident 2 was initiated on 10/24/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Physician Orders dated 9/26/23, showed the physician orders for a low bed with bilateral side rails up per the resident's request and no side rails use attempted. Review of the facility's Side Rail assessment dated [DATE], showed the previous side rail alternatives attempted were a low bed and PT/OT. Review of Resident 2's medical record failed to show the outcome of least restrictive alternatives before attempting side rail use. On 10/24/23 at 0829 hours, Resident 2 was observed laying in bed with bilateral side rails up. On 10/24/23 at 0856 hours, Resident 2 was observed in bed with bilateral side rails up. On 10/26/23 at 1619 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 2's side rail use as per the resident's request. The DON was unable to locate documentation to show the outcome of least restrictive alternatives attempted before initiating side rail use. 2. Medical record review for Resident 23 was initiated on 10/24/23. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Physician Order Report for October 2023 showed a physician order dated 7/25/23, for a low bed with bilateral side rails while in bed for seizure activity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 19 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 Review of Resident 23's Side Rail assessment dated [DATE], showed the previous side rail alternatives attempted were a low bed and PT/OT. The assessment also showed the resident had medical justification of side rail use due to seizure activity. Review of Resident 23's medical record failed to show the outcome of least restrictive alternatives before attempting side rail use. Resident 23's medical record also did not show the resident had seizure activity. On 10/24/23 at 0821 hours, 10/25/23 at 0801 and 1140 hours, and 10/26/23 at 0753 hours, Resident 23 was observed laying in their bed with bilateral side rails up. No padding was observed on the bed side rails. On 10/26/23 at 1612 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 23 utilized bilateral side rails, and stated it was for safety due to seizures. When asked when the resident's last seizure was, the DON was unable to locate documented seizure activity. When asked the outcome of least restrictive alternatives use before using the side rails, the DON was unable to find documentation in the resident's medical record. 3. Medical record review for Resident 30 was initiated on 10/24/23. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Physician Orders showed the physician orders dated 8/8/23, for no side rail use attempted and to use bilateral side rails for safety due to seizure activity. Review of Resident 30's Side Rail assessment dated [DATE], Resident 30's admission date, showed previous side rail alternatives attempted were a low bed and PT/OT. Review of Resident 30's medical record failed to show the outcome of least restrictive alternatives before attempting side rail use. Resident 30's medical record did not show the resident had seizure activity. Review of Resident 30's medical record failed to show the outcome of least restrictive alternatives before attempting side rail use. The DON was also unable to find documentation of seizure activity. On 10/24/23 at 0856 hours, Resident 30 was observed in bed with bilateral side rails up. On 10/26/23 at 1558 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 30 had bilateral side rails, and was unable to locate in Resident 30's medical record for the outcome of least restrictive alternatives used before attempting side rails use. When asked for the resident's seizure activity, the DON was unable to locate the record of seizure activity in the resident's medical record. When asked the outcome of least restrictive alternatives used before attempting side rails use, the DON was unable to find any in the resident's medical record. 4. Medical record review for Resident 31 was initiated on 10/24/23. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's Physician Orders showed the physician orders dated 8/12/23, for no side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 20 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 rail use was attempted and for bilateral side rails for safety per the family's request. Level of Harm - Minimal harm or potential for actual harm Review of Resident 31's Side Rail assessment dated [DATE], showed the previous alternatives used were a low bed and PT/OT. Residents Affected - Few Review of Resident 30's medical record failed to show the outcome of least restrictive alternatives before attempting side rail use. On 10/24/23 at 0856 hours, and 10/25/23 at 0756 hours, Resident 31 was observed in bed with bilateral side rails up. On 10/26/23 at 1615 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 31's bilateral side rails were implemented due to the resident's family request. The DON was unable to locate the outcome of least restrictive alternatives used before attempting side rail use in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 21 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review the facility failed to ensure one of 14 final sampled residents (Resident 12) was free from the unnecessary medications (Resident 12). * The facility failed to monitor orthostatic hypotension for Resident 12 who was on quetiapine, an antipsychotic (reduce or relieve symptoms such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there) medication. This posed the risk of not identifying the potential harmful side effects associated with the medication and a delay in necessary medical interventions for this resident. Findings: According to Lexicomp, quetiapine may cause orthostatic hypotension and accompanying tachycardia and syncope in adults, particularly with rapid titration. Orthostatic hypotension may result in subsequent falling and fracture. Mechanism: Orthostatic hypotension is attributed to alpha-1 adrenergic receptor antagonism. Risk factors: Known cardiovascular disease (history of myocardial infarction or ischemic heart disease, heart failure, or conduction abnormalities) or cerebrovascular disease, known predisposing conditions (such as, hypovolemia or dehydration) and use of other medications that also cause or exacerbate orthostatic hypotension (such as tricyclic antidepressants and antihypertensive medications). Review of Resident 12's medical record was initiated on 10/27/23. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's previous acute care hospitalization progress note dated 9/16/22, showed a diagnosis of Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]). Review of Resident 12's current medications dated 10/26/23, showed quetiapine (antipsychotic) 25 mg via GT twice a day. Review of Resident 12's routine psychotropic medication for October 2023, showed to monitor adverse reaction every shift; however, the document failed to show the monitoring of Resident 12's blood pressure while lying, sitting, and standing. On 10/27/23 at 0843 hours, an interview with LVN 1 was conducted. LVN 1 stated Resident 12 used quetiapine for the behavior of pulling out the GT tubing. The LVN was asked how Resident 12 was being monitored for orthostatic hypotension, LVN 1 stated Resident12's BP was monitored everyday but not for orthostatic hypotension. On 10/27/23 at 1505 hours, the DON was made aware and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 22 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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** 3. Review of the facility's P&P titled Labeling/ Storage of Medication revised on 6/2013 showed an external medications in liquid, tablet, capsule, or powder form will be segregated from drugs for internal use. On 10/27/23 at 0754 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 9, and the following was observed: - One open bottle of artificial tears (used to lubricate dry eyes) was stored next to one individually packed metoprolol (used to treat high blood pressure) tablet inside a drawer labeled with the residents' room number. LVN 9 verified the above findings. LVN 9 stated the above medications were stored inside the drawer because they were not available in the unit's Pyxis (automated medication dispensing system). 4. On 10/26/23 at 1527 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 6, and the following was observed: - One open tube of Oragel (used to relieve pain of the mouth and gums) mouth sore gel was stored next to an open bottle of artificial tears, two individually packed furosemide (medication used to reduce extra fluid in the body) tablets, and one individually packed losartan potassium (used to treat high blood pressure) tablet. LVN 6 verified the above findings. LVN 6 stated the above medications were stored inside the drawer because those medications were not available in the unit's Pyxis. LVN 6 stated the above medications were delivered by the pharmacy. 2. On 10/24/23 at 0843 hours, during the initial tour, the acetylcysteine and Refresh eye drop medications were observed in a plastic bag on the enteral pump pole of Resident 16's room. On 10/24/23 at 0900 hours, an interview with LVN 2 was conducted. LVN 2 was asked regarding the acetylcysteine and Refresh eye drop medications were left at Resident 16's bedside. LVN 2 stated the medications were hanged in the pole because Resident 16 was on enhanced precaution. Medical record review for Resident 16 was initiated on 10/24/23. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's current medication list showed to administer ocular lubricant ophthalmic (generic name for Refresh eye drop) one drop to left eye every six hours and acetylcysteine 20% inhalation 20% 4 ml inhalation for thick secretion every six hours. On 10/26/23 at 0944 hours, an interview with the DON was conducted. The DON was asked regarding the storage of the medications at Resident 16's bedside. The DON stated there should be no medications stored at bedside. The DON was made aware of the findings and acknowledged. Based on observation, interview, medical record review, and facility P&P review, the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 23 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 failed to ensure the residents' medications were stored properly for one of 14 final sampled residents (Resident 5) and one nonsampled resident (Resident 16), and in two of five medication carts (Medication Carts A and B). * The facility failed to ensure the topical medication was stored properly for Resident 5 when a tube of triamcinolone ointment (a topical ointment used to relieve redness, itching, swelling, or other discomfort caused by skin conditions) was observed on Resident 5's bedside table. * The acetylcysteine (a medication used to help thin and loosen mucus in the airways due to certain lung diseases) and Refresh eye drop (lubricating eye medication to relieve dry eyes) medications were left at Resident 16's bedside. * The facility failed to ensure the internal medications were stored separately from the externally used medications in Medication Carts A and B. These failures had the potential for unauthorized access to the medications, medication error, and negatively affected the residents' well-being. Findings: 1. During the facility's initial tour on 10/23/23 at 0809 hours, a tube of triamcinolone ointment was observed on Resident 5's bedside table. On 10/23/23 at 0834 hours, an interview and concurrent observation was conducted with the DON. The DON verified the tube of triamcinolone ointment on Resident 5's bedside table. The DON stated the triamcinolone ointment should not be left at bedside. Medical record review for Resident 5 was initiated on 10/23/23. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P Examination dated 5/20/23, showed Resident 5 did not have the capacity to understand and make decisions. Review of Resident 5's Physician Order Report for 10/1/23 to 10/31/23, showed a physician's order dated 9/16/23, to apply triamcinolone ointment 1% twice daily for 21 days for generalized eruptions. On 10/27/23 at 0956 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 5 was receiving topical treatments twice daily for skin eruptions on his body. LVN 4 stated the treatment nurse was responsible for applying the medication. LVN 4 also stated the topical medication should be kept in the cart. On 10/27/23 at 1400 hours, a follow-up interview was conducted with the DON. The DON verified the above findings. The DON further stated the triamcinolone ointment should be kept in the treatment cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 24 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operation of the Food and Nutrition Services Department. * [NAME] 1 was unable to perform the thermometer calibration as per the facility's P&P. This had the potential for inaccurate food temperature readings and could lead to foodborne illnesses in a highly susceptible populations of residents who received food preparation in the kitchen. Findings: Review of the facility's P&P titled Thermometer Use and Accuracy Monitoring dated 10/2010 showed the purpose of the policy is to ensure accuracy of thermometers and correct measurement of temperatures throughout the facility. The Calibrating a Food Thermometer Using Ice Point Method section showed the following steps: - Fill a large container with crushed ice; - Add clean tap water until container is full; - Stir the mixture well; - Put the thermometer probe into the ice water so sensing area is completely submerged; - Wait 30 seconds or until the indicator stops moving; - Do not let the probe touch the bottom or sides of the container; - Hold the calibration nut securely with wrench or other tool; and - Rotate the head of the thermometer as needed until it reads 32 degrees F. On 10/25/23 at 1203 hours, a thermometer calibration observation and concurrent interview was conducted with [NAME] 1, with the Dietary Clerk present. The following was observed: - [NAME] 1 prepared a cup with ice and water; - [NAME] 1 placed a digital thermometer into the slush. The tip of the digital thermometer was touching the bottom of the cup. The thermometer showed a reading of 32.5 degrees F; - [NAME] 1 placed a second digital thermometer into the slush. The tip of the digital thermometer was touching the bottom of the cup. The thermometer showed a reading of 32.7 degrees F; - [NAME] 1 placed a third digital thermometer into the slush. The tip of the digital thermometer was touching the bottom of the cup. The thermometer showed a reading of 32 degrees F; - [NAME] 1 and the Dietary Clerk verified the tips of all three digital thermometers were touching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 25 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0802 the bottom of the cup. Level of Harm - Minimal harm or potential for actual harm Review of the Monthly Kitchen Sanitation Checklist showed the documentation of food and refrigerator/freezer thermometers present, accurate and calibrated for August, September, and October 2023. Residents Affected - Few On 10/27/23 at 0934 hours, an interview was conducted with the RD. The RD was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 26 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 2. Review of the facility's P&P titled Food Storage revised 10/2010 showed the following: Residents Affected - Few - Foods held in refrigerators or other storage areas shall be appropriately covered; - Food which was prepared and not served shall be stored appropriately, clearly labeled and dated; - Food supplies shall be continuously checked for freshness and expiration date; and - Any expired food items shall be discarded immediately and manager/supervisor shall be notified. On 10/24/23 at 0750 hours, during the initial tour of the kitchen, an observation of the spice shelf area was conducted with the Dietary Clerk. An open bag of hamburger buns was noted on top of spice shelf with a use-by date of 10/20/23. An observation of the walk-in refrigerator was conducted with the Dietary Clerk. A half of a purple cabbage was noted with a use-by date of 10/21/23, and an open bag of spinach was noted with a use-by date of 10/23/23. The Dietary Clerk verified the findings. On 10/25/23 at 1345 hours, an observation of the dry storage area was conducted with the RD. There was a bag of bagels with a use-by date of 10/21/23. The RD verified the findings. 3. On 10/24/23 at 0750 hours, an observation of the walk-in refrigerator was conducted with the Dietary Clerk. An opened bag of grapes was seen with no use-by date. The Dietary Clerk verified the findings. 4. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. On 10/25/23 at 1147 hours, a pureed food preparation observation and concurrent interview was conducted with [NAME] 2, with the RD present. During the pureed food preparation for the pureed green beans, the blender's blades were observed inside the blender's jar and the blender's jar was observed propped into the blender's base. The blender was not dry prior to use. [NAME] 2 and the RD verified the findings. The RD stated the equipment must be air dried and completely dry before use. 5. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 10/24/23 at 0750 hours, a metal cooling rack and a metal sheet tray were observed with brown colored particles. The Dietary Clerk verified the findings. On 10/27/23 at 0934 hours, a follow-up interview was conducted with the RD. The RD was informed and acknowledged the above findings. Based on observation, interview, and facility P&P review, the facility failed to ensure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 27 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 sanitary requirements were met in the kitchen as evidenced by: Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure the cutting boards were kept in a sanitary condition. Residents Affected - Few * The facility failed to ensure a safe working area was provided for staff in the dishwashing room when puddle of water was observed on the floor, which was from the broken hot water booster for the dishwasher. * The facility failed to ensure the proper labeling with open date or use by date of the bacon and sausage stored in the kitchen refrigerator. * The facility failed to ensure the kitchen refrigerator shelves were clean. * The facility failed to ensure the freezer was free from any ice buildup. * The facility failed to ensure the expired food items in the kitchen were discarded. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen were utilized once the food item was opened. * The facility failed to air dry the equipment. * The facility failed to ensure the kitchen equipment were clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: On 10/24/23 at 1240 hours, during an observation, two of 31 residents in the facility were served food prepared from the kitchen. 1. Review of the facility's P&P titled Food Storage revised 10/2010 showed the following: - Storage areas for food are kept neat and clean. - Guidelines for food storage and shell-life of refrigerated foods - Bacon five to seven days - Sausage two days On 10/24/23 at 0748 hours, an initial tour of the kitchen was conducting. The following was observed: * There were five heavily marred chopping boards observed in the dish rack. Dietary Clerk 1 verified the findings. * An observation of the dishwashing room was conducted. The dishwashing machine booster was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 28 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 observed to have dripping water continuously which created a puddle of water on the floor. Dishwasher 1 stated it had been broken. When asked what they had done to fix the machine and for the kitchen staff's safety, Dietary Clerk 1 stated the engineering was aware of the problem. She stated there was a floor mat that the staff put for staff safety. They put the mat after dishes were washed because the cart had to be rolled in the area when washing dishes. Residents Affected - Few * An observation of the walk-in refrigerator with [NAME] 1 was conducted. An opened box of bacon and sausage was seen with no open date or use by date. [NAME] 1 verified the findings. * The shelving of the refrigerator was observed with accumulation blackish material, [NAME] 1 ran his finger across the rack shelving and the blackish material got lifted off from the shelving. [NAME] 1 verified the findings. * An observation of the walk-in freezer with [NAME] 1 was conducted. Accumulation of ice buildup was observed on the freezer door. [NAME] 1 verified the findings. On 10/24/23 at 1508 hours, an interview with the Dietary Manager was conducted. The Dietary Manager stated the bacon and sausage were good for five to seven days after the open date. When the Dietary Manager was asked regarding the dishwasher hot water booster was broken, she stated the dishwasher booster was not functioning as it should, and the hot water booster was ordered since August 2023. The Dietary Manager was made aware and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 29 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Potential for minimal harm Based on interview and medical record review, the facility failed to ensure the facility's arbitration agreement (an agreement between the facility and resident or resident representatives where they would resolve any disputes through a neutral person, rather than through court), specifically provided for the selection of a neutral arbitrator (an impartial, or unbiased third-party decision maker, agreed to by both parties to resolve their dispute) and selection of a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) that was convenient for the residents and/or their representatives. These failures had the potential for residents to be uninformed and negatively affect the ability to resolve any disputes. Residents Affected - Some Findings: Review of the facility's arbitration agreement titled Arbitration of Medical Malpractice Disputes, undated, failed to show explicit language for the selection of a neutral arbitrator, or the selection of a convenient venue agreed upon by both parties. On 10/25/23 at 1335 hours, an interview and concurrent review of the facility's arbitration agreement was conducted with the SW. The SW stated she was responsible for reviewing the contents of the arbitration agreement with the residents and/or resident representatives. On 10/27/23 at 1043 hours, a follow-up interview and concurrent review of the facility's arbitration agreement were conducted with the SW. The SW was asked if the agreement stated how a neutral arbitrator would be selected. The SW declined to answer. The SW was asked if the agreement provided information regarding the selection of venue for arbitration. The SW stated it would be in the hospital, and if the location was not convenient, then it could be discussed. On 10/27/23 at 1326 hours, an interview and concurrent review of the facility's arbitration agreement was conducted with the CEO. The CEO stated he was not aware the facility had an arbitration agreement and that there were residents signed the agreement. The CEO reviewed the facility's arbitration agreement. The CEO was asked whether the agreement mentioned how the neutral arbitrator would be selected, or the selection of a venue for arbitration. The CEO verified the arbitration agreement did not mention the selection of a neutral arbitrator or the selection of a venue convenient to both parties. On 10/27/23 at 1505 hours, the CEO, DON, and DSD were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 30 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 - Potential for minimal harm Based on observation, interview, and facility document review, the facility failed to maintain the essential equipment in safe operating condition. Residents Affected - Some * The facility failed to ensure the hot water booster for the dishwasher was working to maintain the acceptable hot water for the dishwasher to function properly. This failure had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the Engineering Work Order Sheet dated 8/8/23, showed booster heater for the dish machine was not keeping temperature. The booster heater had internal water leak that was shorting out the electrical. Heater was not repairable and would have to be replaced. On 10/24/23 at 0748 hours, an observation of the dishwashing room was conducted. The dishwashing machine booster was observed dripping with water continuously. Dishwasher 1 stated it had been broken for a month. Dietary Clerk 1 stated the engineering was aware about the problem. On 10/24/23 at 1240 hours, during an observation, two of 31 residents in the facility were served food prepared from the kitchen. On 10/24/23 at 1508 hours, an interview with Dietary Manager was conducted. When the Dietary Manager was asked regarding the dishwasher hot water booster was broken, she stated the dishwasher booster was not functioning as it should. The dishwasher was used for pots and pans only. The facility was using chlorine as a sanitizer after going through the dishwasher as the machine could not reach to the temperature of 160 degrees. The Dietary Manager further stated the hot water booster was reported not working since August 2023. The Dietary Manager stated that meals were being served on a disposable dishes and cutlery for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 31 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's Bed Entrapment Check List template showed seven zones to be assessed on the resident's beds with side rails, follows: Zone 1 - gaps within the side rail are less than 4-3/4 inches. Zone 2 - under the rail between rail and mattress is less that 4-3/4 inches. Zone 3 - space between the rail and mattress is less that 4-3/4 inches. Zone 4 - under the rail at the end of the rail is less than 2-3/8 inches. Zone 5 - between split rails: possible neck or chest entrapment Zone 6 - gap between edge rail and head or foot board. Zone 7 - gap between mattress and head or foot board. 4. Medical record review for Resident 2 was initiated on 10/24/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Physician Orders showed the following: - A physician's order dated 9/26/23, for a low bed with bilateral side rails. - A physician's order dated 10/10/23, for a low air loss mattress. Review of the Resident 2's Side Rail assessment dated [DATE], showed the resident was not at risk for entrapment. Review of the facility's Bed Entrapment Risk Checklist failed to show Resident 2's bed was assessed for entrapment. On 10/24/23 at 0856 hours, Resident 2 was observed in bed on a LAL mattress with bilateral side rails up. On 10/25/23 at 1507 hours, and interview and concurrent record review were conducted with the Maintenance Staff. The Maintenance Staff stated the process was to evaluate all resident beds for entrapment on admission and annually. The Maintenance Staff reviewed the Bed Entrapment Risk Checklist and stated he was unable to show Resident 2's bed was assessed for entrapment on their admission. On 10/26/23 at 1309 hours, an interview was conducted with the Facilities Director. The Facilities Director stated for LAL mattresses, the subacute unit staff were responsible to letting maintenance staff know when a mattress was changed so they could conduct a new entrapment assessment and ensure the new mattress was compatible with the bed. The Facilities Director stated they had not been asked in awhile to inspect a LAL mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 32 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/26/23 at 1346 hours, an interview was conducted with the DON. The DON stated the maintenance staff should be checking for bed compatibility and entrapment when a mattress was replaced with a LAL mattress. The DON was unable to provide documentation to show Resident 30's bed was assessed for compatibility and entrapment with the LAL mattress. On 10/27/23 at 1026 hours, an interview was conducted with the DON. The DON stated the RN also assessed the residents for entrapment when completing the Side Rail Assessment. On 10/27/23 at 1045 hours, and interview was conducted with RN 1. RN 1 was stated she assessed the residents for entrapment when completing the Side Rail Assessment. When asked how the RN assessed for entrapment, the RN replied if the resident could not move or requires a lot of assistance to move, they were not a risk for entrapment. The RN stated they also visually assessed for entrapment by looking at the resident in bed and seeing if there was enough space between the resident and headboard, foot board; and the space between the side of the resident's body and the side rail to see if they needed a longer bed or a bariatric bed. When asked if she used a tool or measuring device when assessing for entrapment, RN 1 stated no. 5. Medical record review for Resident 30 was initiated on 10/24/23. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Physician Orders showed the following: - A physician's order dated 8/8/23, for a low bed with bilateral side rails. - A physician's order dated 8/9/23, for a low air loss mattress. Review of the Resident 30's Side Rail assessment dated [DATE], showed the resident was not at risk for entrapment. Review of the facility's Bed Entrapment Risk Checklist failed to show Resident 30's bed was assessed for entrapment. On 10/24/23 at 0817 hours, Resident 30 was observed in bed on a LAL mattress with bilateral side rails up. On 10/25/23 at 1507 hours, and interview and concurrent record review were conducted with the Maintenance Staff. The Maintenance Staff stated the process was to evaluate all resident beds for entrapment on admission and annually. The gaps were measured at each zone per the checklist to ensure they were less than the required measurement. The Maintenance Staff reviewed the Bed Entrapment Risk Checklist and stated he was unable to show Resident 30's bed was assessed for entrapment on their admission and for the LAL mattress use. On 10/26/23 at 1346 hours, an interview was conducted with the DON. The DON stated the maintenance staff should be checking for bed compatibility and entrapment when a mattress was replaced with a LAL mattress. The DON was unable to provide documentation to show Resident 30's bed was assessed for compatibility and entrapment with the LAL mattress. On 10/27/23 at 1026 hours, an interview was conducted with the DON. The DON stated the RN also assessed the residents for entrapment when completing the Side Rail Assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 33 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/27/23 at 1045 hours, and interview was conducted with RN 1. RN 1 was stated she assessed the residents for entrapment when completing the Side Rail Assessment. When asked how the RN assessed for entrapment, the RN replied if the resident could not move or requires a lot of assistance to move, they were not a risk for entrapment. The RN stated they also visually assessed for entrapment by looking at the resident in bed and seeing if there was enough space between the resident and headboard, foot board; and the space between the side of the resident's body and the side rails to see if they need a longer bed or a bariatric bed. When asked if she used a tool or measuring device when assessing for entrapment, RN 1 stated no. 6. Medical record review for Resident 23 was initiated on 10/24/23. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Physician Order Report: 10/1/23-10/31/23, showed a physician order dated 7/25/23, for a low bed with bilateral side rails. Review of the facility's Annual Bed Entrapment Risk Checklist dated 12/5/22, showed a bed in Room B was assessed for entrapment. The check list failed to include a resident or bed specific identifier. Review of Resident 23's Side Rail assessment dated [DATE], showed Resident 23 was at risk for entrapment. On 10/25/23 at 1507 hours, an interview and concurrent record review were conducted with Maintenance Staff. Maintenance Staff stated the process was to evaluate all resident beds for entrapment on admission and annually. The Maintenance Staff reviewed the Annual Bed Entrapment Risk Checklist dated 12/5/23, and stated the list only showed room numbers, not resident or bed specific identifiers; and did not clearly specify Resident 23's bed was evaluated annually for entrapment. On 10/27/23 at 1026 hours, an interview was conducted with the DON. The DON stated the RN also assessed the residents for entrapment when completing the Side Rail Assessment. On 10/27/23 at 1045 hours, and interview was conducted with RN 1. RN 1 stated she assessed the residents for entrapment when completing the Side Rail Assessment. When asked how the RN assessed for entrapment, the RN replied if the resident could not move or did not require a lot of assistance to move, they were not a risk for entrapment. The RN stated they also visually assessed for entrapment by looking at the resident in bed and seeing if there was enough space between the resident and the headboard, foot board; and the space between the side of the resident's body and the side rails. When asked if she used a tool or measuring device when assessing for entrapment, RN 1 stated no. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for six of 14 final sampled residents (Residents 2, 13, 18, 23, 30, and 32) and one nonsampled resident (Resident 19). * The facility failed to ensure Resident 13's bed entrapment assessment was completed with bed inspection gap measurements. * The facility failed to ensure Resident 18's bed entrapment assessment was completed with bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 34 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 inspection gap measurements. Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure Resident 19's bed entrapment assessment was completed with bed inspection gap measurements. Residents Affected - Few * The facility failed to ensure Resident 2 was assessed for entrapment on admission and failed to ensure Resident 2's (low air loss) LAL mattress and bed were assessed to be safe and compatible together. * The facility failed to ensure Resident 30's LAL mattress and bed were assessed to be safe and compatible together. * The facility failed to document Resident 23's annual Bed Entrapment Check List completed on 12/5/22, identified the resident and specific bed assessed. * The facility failed to ensure bed inspection gap measurement for bed entrapment assessment were completed and documented for Resident 32. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Preventive Maintenance (PM) System dated 4/2019 showed the purpose of the policy is to ensure the routine scheduling of maintenance on equipment and utility systems. The Facilities Engineering will maintain a preventative maintenance system for the continuous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 35 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 scheduling of maintenance of all times included in the Equipment and Utility Management Programs. Level of Harm - Minimal harm or potential for actual harm A concurrent observation, medical record review, and facility document review for Residents 13, 18, and 19 showed the residents' bed entrapment assessment were not completed or the bed inspection gap measurements from bed to side rails were not recorded. Residents Affected - Few 1. On 10/24/23 at 0840 hours, 10/25/23 at 1046 hours, and 10/26/23 at 0757 hours, Resident 13 was observed lying in bed with bilateral side rails elevated. Medical record review for Resident 13 was initiated on 10/24/23. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 11/3/22, showed Resident 13 did not have the capacity to understand and make medical decisions and had Parkinson's Disease. Review of Resident 13's physician's order dated 8/22/23, showed to provide low bed with bilateral side rails up when in bed for safety per the family's request due to Parkinson's Disease (a brain disorder that causes uncontrollable movements, such as shaking). However, further review of the medical record failed to show documented evidence the side rail entrapment assessment was completed and documented. Review Resident 13's plan of care addressing the use of side rails showed the interventions included to assess the resident for any risk of entrapment for bed side rails use and appropriateness of bed side rails use based on the resident's size and weight. Review of Resident 13's Notice of Room Change/New Roommate dated 12/13/22, showed Resident 13 was moved from room [ROOM NUMBER] bed #3 to room [ROOM NUMBER] bed #1. On 10/26/23 at 0847 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD verified Resident 13 had bilateral side rails elevated. The DSD was informed and verified the above findings. 2. On 10/24/23 at 0844 hours, 10/25/23 at 1044 hours, 10/25/23 at 1420 hours, and 10/26/23 at 0758 hours, Resident 18 was observed lying in bed with bilateral side rails elevated. Medical record review for Resident 18 was initiated on 10/24/23. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's physician's order dated 9/19/23, showed to provide low bed with bilateral padded side rails up for safety due to seizure disorder (sudden, uncontrolled burst of electrical activity in the brain). However, further review of the medical record failed to show documented evidence the side rail entrapment assessment was completed and documented. Review Resident 18's plan of care addressing the use of side rails showed the interventions included to monitor the resident to assure the resident was properly positioned when in bed and to provide an ongoing assessment for tolerance to current side rail. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 36 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 18's Notice of Room Change/New Roommate dated 5/4/23, showed Resident 13 was moved from room [ROOM NUMBER] bed #3 to room [ROOM NUMBER] bed #2. On 10/25/23 at 1421 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified Resident 18 had bilateral side rails elevated. LVN 3 stated Resident 18's side rails were used as seizure precaution. 3. On 10/24/23 at 0904 hours, Resident 19 was observed lying in bed with four side rails elevated. Medical record review for Resident 19 was initiated on 10/24/23. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 12/2/22, showed Resident 19 had seizure disorder. Review of Resident 19's Physician Order Report from 10/1/23 to 10/31/23, showed a physician's order dated 6/17/23, to provide four side rails up when in bed for safety related to seizure disorder per the family's request and to place specialty bed for wound management. Review of Resident 19's Physician Order Report dated 1/1/23 to 1/31/23, showed a physician's order dated 12/2/21, to provide Citadel bed (special bed frame and mattress used to provide support for the resident and staff using them) for wound management. However, further review of the medical record failed to show documented evidence the side rail entrapment assessment was completed and documented. Review Resident 19's plan of care addressing the use of side rails showed the interventions included to monitor the resident to assure the resident is properly positioned when in bed and to provide an ongoing assessment for tolerance to current side rail. On 10/26/23 at 0852 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD verified Resident 19 had a specialty bed with four side rails elevated and air mattress. The DSD was informed and verified the above findings. On 10/25/23 at 1547 hours, an interview and concurrent facility document review was conducted with the Maintenance Staff. The Maintenance Staff stated he conducted the entrapment assessment annually and as needed when the nursing department informed the maintenance department of new residents with side rail orders. The Maintenance Staff stated he documented the annual entrapment assessment on the Bed Entrapment Risk Checklist forms. The Maintenance Staff was able to show the documentation for the annual bed assessment dated [DATE]. However, there were no specific name of the residents on the assessment form. When asked how he identified which specific resident the annual entrapment assessment was completed for, the Maintenance Staff stated he was just using the residents' room numbers because all the residents in the subacute unit had the same beds and mattresses. When asked if Resident 19's bed and mattress was the same as the other residents' bed and mattress in the subacute unit, the Maintenance Staff stated Resident 19's bed was a rental. The Maintenance Staff verified Resident 19 had four side rails elevated. The Maintenance Staff was not able to show the copies of the Bed Entrapment Risk Checklist completed for Residents 13, 18, and 19. On 10/26/23 at 1309 hours, an interview and concurrent facility document review was conducted with the Facilities Director. The Facilities Director verified the annual Bed Entrapment Risk Checklist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 37 of 38 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 555567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Global Medical Center D/P Snf 2701 South Bristol Street Santa Ana, CA 92704 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 0909 Level of Harm - Minimal harm or potential for actual harm dated 12/5/22, did not show the resident's name. When asked if he could identity which resident the entrapment assessment was completed for, the Facilities Director stated he could not. The Facilities Director was not able to show the copy of the Bed Entrapment Risk Checklist completed for Resident 18 who was admitted after the annual entrapment assessment was completed and documented on 12/5/22. Residents Affected - Few 7. On 10/24/23 at 0843 hours, Resident 32 was observed in bed with bilateral siderails up. Medical record review for Resident 32 Medical record review for Resident 32 was initiated on 10/24/23. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's Physician Order Report for 10/1/23 - 10/31/23 showed a physician's order dated 8/28/23, for a low bed with bilateral side rails up times 2 per the family's request for diagnosis of seizure. Review of Resident 32's care plan dated 8/28/23, showed a care plan problem addressing the risk for injury during seizures with the approached plan to use side rails times 2 when in bed included in the intervention. On 10/26/23 at 1440 hours, an interview and concurrent facility record review was conducted with the Facilities Director. The Facilities Director was unable to locate Resident 32's bed inspection gap measurement assessment upon Resident 32's admission to the facility. On 10/27/23 at 1145 hours, an interview was conducted with the DON. The DON was asked about the process for informing the Engineering Department of the resident's new admission to inspect the bed for gap measurement. The DON stated the nursing department would email engineering department to inform of admission and usually the engineering department would inform the nursing verbally when the assessment was completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555567 If continuation sheet Page 38 of 38