Health inspection·April 28, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Potential for minimal 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 one of 35 final sampled residents (Resident 115) was safe to self-administer the medications. Residents Affected - Some * The facility failed to ensure the plastic containers filled with Halls Menthol Cough and Throat Relief (cough drop) were not stored in Resident 115's cabinet and bedside table. This failure had the potential for the resident to administer the medication inaccurately, develop adverse reactions from the medication, and negatively affect the residents' well-being. Findings: Review of the facility's P&P titled Resident Self Administer Medications revised March 2023 showed the IDT supports the right of each resident to self-administer medications when this practice is clinically appropriate. The Procedure section showed a resident may only self-administer medications after the IDT has determined which medications may be self-administered. On 4/21/25 at 0822 hours, during the initial tour of the facility, the plastic containers filled with Halls Menthol Cough and Throat Relief were observed on Resident 115's cabinet and bedside table. Resident 115 was not in the room. On 4/21/25 at 0913 hours, an observation and concurrent interview as conducted with LVN 1. LVN 1 verified the findings and stated Resident 115 was not allowed to have the cough drops at the bedside. When asked, LVN 1 stated he was responsible for checking the resident's room for safety issues and any medications at the bedside. Medical record review for Resident 115 was initiated on 4/21/25. Resident 115 was admitted to the facility on [DATE]. Review of Resident 115's Self Administration of Medication assessment dated [DATE], showed the resident was not physically able to administer his own medications and the licensed nurses were to administer the medications as per the facility's protocols. Review of Resident 115's H&P examination dated 3/6/25, showed Resident 115 had the capacity to understand and make decisions. Review of Resident 115's plan of care failed to show a care plan problem addressing Resident 115's ability to self-administer the medications prior to 4/21/25. Review of Resident 115's Order Summary Report dated 4/23/25, showed a physician's order dated 4/21/25, allowing Resident 115 to keep the Halls cough drops at the bedside and to consume as needed. However, further review of Resident 115's physician's orders failed to show the orders for the Halls cough drops and/or for the resident to self-administer the Halls cough drops prior to 4/21/25. On 4/22/25 at 0939 hours, an observation and concurrent interview was conducted with Resident 115. The plastic container filled with the Halls cough drops was observed in the resident's cabinet. Resident 115 stated the Halls cough drops were brought into the facility by his family member. Resident 115 stated he administered the Halls cough drop independently and as needed. Resident 115 further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 2 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 stated the facility staff were aware he had the Halls cough drops at the bedside. Level of Harm - Potential for minimal harm On 4/22/25 at 1431 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 115 did not have the physician's orders for the Halls cough drop and/or for the resident to self-administer the Halls cough drop prior to 4/21/25. LVN 1 further verified Resident 115's Self Administration of Medication assessment dated [DATE], showed the licensed nurses were to administer the resident's medications. LVN 1 stated he had notified Resident 115's physician and updated the resident's medical record on 4/21/25, after he was informed of the above findings. Residents Affected - Some On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 3 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to determine and clarify whether two of four final sampled residents (Residents 123 and 785) reviewed for advanced directives had formulated an advance directive for healthcare. * Resident 123's medical record showed conflicting documentation as to whether the resident had formulated an advance directive. * The facility failed to determine if Resident 785 had formulated an advanced directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directive revised 1/2025 showed the residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation of the resident's desires on a routine basis and when there is a significant change in the resident's condition. 1. Medical record review for Resident 123 was initiated on 4/21/25. Resident 123 was admitted to the facility on [DATE]. Review of Resident 123's POLST dated 1/27/23, showed Resident 123 had formulated an advanced directive for healthcare on 2/1/23, and had designated her spouse as her health care agent. However, Resident 123's medical record did not contain a copy of Resident 123's advanced directive. Review of Resident 123's Psychosocial assessment dated [DATE], showed Resident 123 had not formulated an advanced directive. On 4/23/25 at 0920 hours, an interview was conducted with Resident 123. Resident 123 stated she believed she had formulated an advanced directive for the healthcare in the past and designated her spouse to make healthcare decisions for her in the event she was to become incapacitated and no longer able to make health care decisions. Resident 123 stated if the facility was unable to obtain a copy of her advanced directive, she wished to formulate another advanced directive. On 4/23/25 at 0927 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated she would attempt to locate a copy of Resident 123's advanced directive for healthcare. Family Member 2 stated she had made medical decisions for Resident 123 in the past. Family Member 2 stated Resident 123 was incapacitated while residing in the acute care hospital and at that time, she made medical decisions on Resident 123's behalf. Family Member 2 stated if she was unable to locate a copy of Resident 123's advance directive, she along with Resident 123 would like to formulate another advanced directive for healthcare. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 4 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm On 4/23/25 at 1000 hours, an interview and concurrent medical record review was conducted with the Social Worker. The Social Worker verified Resident 123's medical record failed to contain a copy of Resident 123's advanced directive for health care. The Social Worker stated he had yet to follow up with Family Member 2 to obtain a copy of Resident 123's advance directive. The Social Worker stated he would contact Family Member 2 and attempt to obtain a copy of Resident 123's advance directive. Residents Affected - Few 2. Medical record review for Resident 785 was initiated on 4/21/25. Resident 785 was admitted to the facility on [DATE]. Review of Resident 785's H&P examination dated 4/17/25, showed the resident had no capacity to understand and make decisions. Review of Resident 785's Physician Orders for Life-Sustaining Treatment (POLST) dated 4/17/25, showed section D was incomplete and did not show if the resident had an advance directive. Review of Resident 785's Resident IDT Care Conference Review dated 4/18/25, showed under the section Care Areas, the facility staff reviewed the resident's advance directive/POLST. On 4/22/25 at 1300 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 785's POLST section D was incomplete and did not show if the resident had an advance directive. On 4/22/25 at 1146 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 785's POLST was incomplete and did not show if the resident had an advance directive. The SSD stated she was responsible to follow up with the resident and/or his responsible party to determine if he had an advance directive and to ensure the resident's POLST was completed. The SSD verified she had not followed up with the resident and/or his responsible party to determine if he had an advance directive, or if he wanted to formulate an advance directive. On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 5 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Potential for minimal harm Based on observation, interview, and facility document review, the facility failed to ensure the residents' privacy was maintained when the confidential resident roster (a list which identified the names of the residents by their, to protect the residents' identities) for the abbreviated survey completed on 10/12/21, was in the survey binder and available for public view. This failure had the potential to result in a violation of the residents' rights in maintaining and upholding confidentiality with the residents' protected health information. Residents Affected - Some Findings: On 4/24/25 at 1312 hours, the facility's survey results binder was observed at the receptionist desk located in the front lobby. The binder included the Confidential Resident Roster showing the resident names for an abbreviated survey for a complaint intake. The resident roster had Confidential printed diagonally across the page in a large gray font. On 4/24/25 at 1308 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator verified the confidential resident roster was in the survey binder and accessible for public view. The Administrator stated the confidential resident roster should not have been in the binder. On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 6 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of three sampled residents (Resident 183) reviewed for the closed records. This failure had the potential for inaccurate data submitted for quality measures. Residents Affected - Some Findings: Closed medical record review for Resident 183 was initiated on 4/24/25. Review of Resident 183's Discharge Summary note dated 3/11/25 at 1230 hours, showed the resident was discharged to the community. Review of Resident 183's discharge MDS assessment dated [DATE], showed the resident was discharged to a short-term acute care hospital. On 4/24/25 at 1620 hours, an interview and concurrent closed medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident 183's closed medical record and verified the resident was discharged to the community. The MDS Coordinator verified the discharge MDS assessment was inaccurately coded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 7 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 92 was initiated on 4/21/25. Resident 92 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 92's Acute Care Hospital 1 Neurological Progress Note dated 3/5/25, showed Resident 92 had a diagnosis of depression and was prescribed citalopram 10 mg orally at night. Review of Resident 92's Level I PASRR screening dated 3/6/25, showed Resident 92 had no diagnosis of serious mental illness. Review of Resident 92's Mental Status Examination dated 3/17/25, showed Resident 92 had a diagnosis of major depressive disorder. The examination showed documentation Resident 92 was observed in his room withdrawn, staring blankly at the wall, and with poor eye contact. On 4/28/25 at 1020 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 92's Level I PASRR screening dated 3/6/25, failed to show Resident 92 had a diagnosis of major depressive disorder. The DON stated the Level I PASRR should have included Resident 92's diagnosis of depression to determine if a Level II mental health evaluation referral was necessary, and to ensure Resident 92 received the appropriated care and services (for mental illness) while residing in the facility. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Level I PASRR contained accurate information for two of two final sampled residents (Residents 92 and 135) reviewed for PASRR screening. * Resident 135 had a diagnosis of unspecified psychosis (a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality) and major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning) and was prescribed olanzapine (an antipsychotic medication); however the Level I PASRR showed Resident 135 had no serious mental illness and was not prescribed any psychotropic medications. * Resident 92 had a diagnosis of major depressive disorder and was prescribed citalopram (an antidepressant medication); however, the Level I PASRR showed Resident 92 had no serious mental illness. These failures posed the risk for the residents' inappropriate placement in a long-term care nursing home when a PASRR Level II evaluation was not done. Findings: Review of the facility's P&P titled Preadmission Screening and Resident Review (PASRR) revised 1/2025 showed the facility ensures each resident is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the extent possible, and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate. PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care. The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 8 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm mental disorders, intellectual disabilities, and related conditions. The purpose of the Level I pre-admission screening is to identify individuals who have or may have a MD/ID or a related condition, who would then require a PASARR Level II evaluation and determination prior to admission to the facility. A positively Level I screen necessitates an in-depth evaluation of the individual, by the state-designated authority, known as Level II PASARR, which must be conducted prior to admission to the facility. Residents Affected - Few 1. Medical record review for Resident 135 was initiated on 4/21/25. Resident 135 was admitted to the facility on [DATE], with the diagnoses of unspecified psychosis and major depressive disorder. Review of Resident 135's H&P examination dated 7/18/24, showed Resident 135 had no capacity to understand and make decisions. Review of Resident 135's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 7/18/24, showed Resident 135 had no diagnosis of serious mental illness and had not been prescribed psychotropic medications. The form showed the Level I screening was negative and Level II evaluation was not required. Review of Resident 135's Order Summary Report dated 4/23/25, showed a physician's order dated 7/18/24, to administer olanzapine 10 mg one tablet by mouth at bedtime for psychosis manifested by sudden angry outburst. On 4/23/25 at 1038 hours, an interview and concurrent medical record review for Resident 135 was conducted with the DON. The DON stated prior to the resident's admission to the facility, a PASRR screening would be conducted for the resident at the acute care hospital. The results of the screening would be sent to the facility and reviewed by the DON for accuracy. The DON stated upon review of the PASRR Level I Screening, if the screening was inaccurate, she would amend the Level I Screening by completing a Resident Review Status Change. The DON reviewed Resident 135's medical record and verified the above findings. The DON stated Resident 135's Level I PASRR Screening was inaccurate, and a Resident Review Status Change should have been completed. On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 9 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed or implemented for three of 35 final sampled residents (Residents 13, 80, and 143). * The facility failed to implement Resident 143's care plan specific to the PICC line management. * The facility failed to develop a care plan problem to address Resident 13's use of an e-cigarette and safe smoking practices. * The facility failed to develop a care plan problem addressing Resident 80's LUA midline catheter use. These failures placed the residents at risk for not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Plans-Timing revised 1/2025 showed each resident has a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative. 1. Medical record review for Resident 143 was initiated on 4/21/25. Resident 143 was admitted to the facility on [DATE]. Review of Resident 143's Order Summary Report showed an order dated 3/13/25, to administer daptomycin (antibiotic medication) 450 mg intravenously once a day for sepsis for six weeks. On 4/21/25 at 1025 hours, an observation and concurrent interview was conducted with Resident 143. Resident 143 was observed with a PICC line located on her right arm. Resident 143 stated she had an infection after a recent surgery and was currently receiving a course of IV antibiotic therapy via her PICC line. Review of Resident 143's care plan titled Risk for Infection related to IV site initiated 3/12/25, showed to measure Resident 143's PICC line on admission and after dressing changes. The care plan showed to measure Resident 143's arm circumference three inches above the PICC line insertion site. Review of Resident 143's IV Administration Treatment Records dated 2/2025, 3/2025, and 4/2025, failed to show documentation for the measurements of the PICC line external catheter length or Resident 143's arm circumference when Resident 143's PICC line dressing change was performed on the following dates: 2/17, 2/24, 3/3, 3/10, 3/17, 3/24, 3/31, 4/7, 4/14, and 4/21/25. On 4/24/25 at 1429 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the facility failed to ensure the licensed nurse obtained and documented the measurements of Resident 143's arm circumference and for the PICC line external catheter length, after dressing changes in accordance with Resident 143's care plan for Risk for Infection related to IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 10 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 site. Level of Harm - Minimal harm or potential for actual harm 2. Review of the facility's P&P titled Electronic Cigarette (e-Cigarette) revised 1/2024 showed the residents who express a desire to use a vape or e-Cigarette device will be assessed for capabilities and deficits to use the device safely. The results of the assessment will be documented in the resident's care plan and updated as necessary to reflect the resident's status. Residents Affected - Few On 4/21/25 at 1054 hours, a concurrent observation and interview was conducted with Resident 13 in Resident 13's room. Resident 13 stated he would go to use the vape outside of the facility building and carried his vape with him. Resident 13 was observed to pull out a vape from a pouch attached to the left side of his wheelchair. Resident 13 stated he kept his vape with him, unless he knew he would not be using it, or at nighttime. Medical record review for Resident 13 was initiated on 4/21/25. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's plan of care failed to show a care plan focus was developed to address the resident's use of the vape or smoking. On 4/24/25 at 1328 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 13 used an e-Cigarette. The DON stated for the residents who smoke, they did a smoking assessment and a care plan. The DON verified Resident 13 did not have a care plan developed to address the resident's use of e-cigarette or smoking. Cross reference to F689, example #2. 3. On 4/21/25 at 0828 hours, during the initial tour of the facility, Resident 80 was observed with a midline catheter to the LUA with the dressing dated 4/17/25. Resident 80 stated he was receiving two different types of antibiotic medications in the facility due to a bone infection to his left foot. Medical record review for Resident 80 was initiated on 4/21/25. Resident 80 was admitted to the facility on [DATE]. Review of Resident 80's H&P examination dated 3/13/25, showed Resident 80 had the capacity to understand and make decisions. Review of Resident 80's plan of care showed a care plan problem dated 3/21/25, addressing Resident 80's RUA PICC line use. Review of Resident 80's Midline Insertion Record dated 4/17/25, showed the LUA midline catheter was inserted because the previous IV access on the RUE was infiltrated (occurs when the fluids or medications intended to be delivered into a vein leak into the surrounding tissue instead of the bloodstream) and came out of the resident's arm. Further review of Resident 80's plan of care failed to show a care plan problem addressing the resident's LUA midline catheter inserted on 4/17/25. On 4/23/25 at 0938 hours, an observation and concurrent interview was conducted with Resident 80. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 11 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 80 was observed with a midline catheter to the LUA. Resident 80 stated he accidentally pulled out the previous IV access on his RUA when he was putting on his sweater sleeve. Resident 80 further stated the facility staff immediately responded and a licensed nurse from an outside company placed a midline catheter to his LUA on 4/17/25. On 4/23/25 at 0958 hours, an interview and medical record review was conducted with RN 1. RN 1 verified Resident 80's IV access was changed to a LUA midline catheter on 4/17/25, and there was no care plan developed to address the resident's LUA midline catheter. On 4/23/25 at 1108 hours, an interview and medical record review was conducted with the DON. The DON verified there was no care plan developed to address Resident 80's LUA midline catheter use. On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 12 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 77 was initiated on 4/22/25. Resident 77 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 77's quarterly MDS assessment dated [DATE], showed Resident 77 with a BIMS score of 13, which indicated the resident was cognitively intact. Review of Resident 77's Order Summary Report for April 2025 showed the following physician's order: - dated 7/6/23, to administer Novolin R (medication to lower blood sugar) Injection Solution 100 unit per ml subcutaneously before meals and at bedtime per the sliding scale as follows: * if the blood sugar level less than 70 mg/dL, give orange juice and/or cookies; and if unresponsive or remains less than 70 mg/dL, give glucagon (medication to increase blood sugar) one mg IM one time and call the MD, * for blood sugar level of 70 to 150 mg/dL, give zero units of insulin, * for blood sugar level of 151 to 200 mg/dL, give three units of insulin, * for blood sugar level of 201 to 250 mg/dL, give six units of insulin, * for blood sugar level of 251 to 300 mg/dL, give nine units of insulin, * for blood sugar level of 301 to 350 mg/dL, give 12 units of insulin, and * for blood sugar level of 351 to 400 mg/dL, give 15 units of insulin and call the MD. Review of Resident 77's MAR for April 2025 showed Resident 77's blood sugar levels were between 351 to 400 mg/dL and had received 15 units of Novolin R insulin at 1630 hours, on the following dates: - on 4/3/25, the blood sugar level was 382 mg/dL. - on 4/10/25, the blood sugar level was 361 mg/dL. Further review of Resident 77's medical record showed no documented evidence Resident 77's physician was notified when the resident's blood sugar levels were between 351 to 400 mg/dL as per the physician's order. On 4/25/25 at 1516 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 stated the physician should have been notified for the blood sugar readings above 351 mg/dL as per the physician's order. LVN 4 further stated there was no documented evidence Resident 77's physician was notified of the elevated blood sugar readings on 4/3 and 4/10/25. On 4/28/25 at 0925 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated she expected the license nurses to call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 13 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's physician if the blood sugar level was between 351 to 400 mg/dL as ordered. The DON verified there was no documented evidence Resident 77's physician was notified of the elevated blood sugar levels on 4/3 and 4/10/25. The DON stated the physician should have been notified of the resident's elevated blood sugar levels so the physician could adjust the resident's insulin orders appropriately. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 35 final sampled residents (Residents 44 and 77). * The facility failed to ensure the TLSO brace was applied to Resident 44 as per the physician's order. * The facility failed to ensure Resident 77's physician was notified when the resident had the blood sugar levels between 351- 400 mg/dL as ordered. These failures had the potential to affect Resident 44 and 77's well-being. Findings: 1. On 4/21/25 at 1034 hours, Resident 44 was observed lying in her bed and sleeping. There was a TLSO brace observed on her wheelchair. Medical record review for Resident 44 was initiated on 4/21/25. Resident 44 was admitted to the facility on [DATE]. Review of Resident 44's Order Summary Report dated 4/24/25, showed a physician's order dated 4/9/25, to apply the TLSO brace while up on the wheelchair; and may remove when in bed and during ADL care. Review of Resident 44's plan of care showed a care plan problem dated 3/12/25, to address Resident 44's risk for falls. The intervention showed for the TLSO brace to be worn at all times while out of bed. On 4/24/25 at 1007 hours, Resident 44 was observed to not be in her room; however, the TLSO brace was observed on top of the desk in her room. On 4/24/25 at 1030 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 44 was in the activities room. LVN 2 stated Resident 44 used the TLSO brace due to a fracture of her T11 (a fracture located at the thoracic spine) and needed the brace on at all times when she was out of bed. LVN 2 was informed of the above findings. LVN 2 then checked Resident 44's room and verified the TLSO brace was not on Resident 44. Afterwards, LVN 2 walked to Dining Room B. Resident 44 was observed sitting in her wheelchair, without the TLSO brace on. LVN 2 then brought Resident 44 to her room and applied the TLSO brace on Resident 44. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 14 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/24/25 at 1317 hours, an interview and concurrent medical record review was conducted with the DOR. The DOR stated Resident 44 had a vertebral (spinal) fracture and required a TLSO brace. The DOR stated the TLSO was recommended by the orthopedic surgeon for the resident to wear for fractures. The DOR stated the TLSO brace prevented for turning or twisting at the spine and maintained an upright posture. The DOR was informed and acknowledged the above findings. The DOR stated Resident 44's physician's order showed for the resident to have the TLSO brace on while up in the wheelchair. On 4/28/25 at 0851 hours, an interview and concurrent medical record review was conducted with the DON and Nurse Consultant. The DON and Nurse Consultant were informed and acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 15 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 13) and one nonsampled resident (Resident 40) remained free from accidents and hazards. * Resident 40's room had items cluttered on multiple surfaces of her room, including the floor. This failure had the potential for injury related to resident care and obstacles when a quick and safe evacuation of the resident was needed in an emergency. * The facility failed to ensure Resident 13 was evaluated to determined if the resident required supervision and could safely store their own e-cigarette. These failures had the potential to put the residents at an increased risk for serious injuries and negative health outcomes. Findings: 1. Review of the facility's P&P titled Free of Accident Hazards/Supervision/Devices revised January 2025 showed the following: - The facility will provide an environment free from accident hazards including in the resident's environment that have the potential to cause injury. The facility will identify, evaluate and analyze the hazards and risks and will implement an individualized, resident centered interventions. Medical record review for Resident 40 was initiated on 4/21/25. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's Social Services progress note dated 7/17/24 at 1514 hours, showed Social Services Staff 1 and the CEO (previous Administrator) met with the resident. The resident had five bedside tables scattered around the resident's room with personal belongings on them. Social Services Staff 1 informed the resident she could only have one tray table for her use, just like the other residents in the facility. Social Services Staff 1 offered to assist the resident in organizing her belongings, and the resident became agitated, yelled, cursed, and used inappropriate name calling towards Social Services Staff 1. Review of the Social Services progress note dated 4/16/25 at 1645 hours, showed Social Services Staff 2 and the Ombudsman met with Resident 40 at her bedside. The Ombudsman expressed concerns regarding the amount of resident belongings in the resident's room and bed. The Ombudsman suggested if some of the clutter could be relocated to enable the licensed nurses and CNAs to provide better care, but the resident refused. On 4/24/25 at 1010 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 40 did not like the facility staff going into her room or touching her belongings. The CNA stated the resident had a lot of belongings around the bed and room, and if the items were in the CNA's way, the resident did not like the facility staff moving them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 16 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/24/25 at 1015 hours, an interview was conducted with LVN 12. LVN 12 stated Resident 40 had a lot of belongings in her room and it was a hazard. LVN 12 stated the resident did not like the facility staff going into her room, unless she called them with the call light. On 4/24/25 at 1026 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated Resident 40's hoarding (mental health condition characterized by acquiring and retaining a large number of possessions) had gotten worse, but the resident did not want the facility staff to touch her belongings. The SSD stated Social Services Staff 1 used to be the assigned Social Services staff, but the resident refused her and now Social Services Staff 2 was assigned to the resident. On 4/24/25 at 1033 hours, an interview was conducted with Social Services Staff 2. Social Services Staff 2 stated he was been assigned to Resident 40 for about two weeks; and when he met with the resident, she would get upset when she was asked to move her belongings. On 4/24/25 at 1044 hours, an interview was conducted with Social Services Staff 1. Social Services Staff 1 stated Resident 40 got upset with her and refused her as her assigned Social Services staff, so a new one Social Services staff was assigned. Social Services Staff 1 stated the facility purchased a small storage shelf for the resident to use, but the resident refused it. On 4/24/25 at 1048 hours, an interview was conducted with the DON. The DON stated the facility spoke to Resident 40 on multiple occasions about her hoarding, but the resident refused to do anything. The DON stated the resident was not currently being followed by a consultant psychiatrist or psychologist. On 4/24/25 at 1428 hours, an observation and concurrent interview was conducted with Social Services Staff 2 at Resident 40's bedside. Upon entering the room, the resident was observed in bed, with three bedside tables, one on each side of the bed and the third one over the foot of the bed. A nebulizer machine and food items were on one tray table, and two water pitchers with straws were on another table. All three bedside tables were covered with multiple items. On the floor, at the foot of the bed was a wash basin filled with nail polish, and boxes on the floor. A TV was sitting on a stand pulled away from the wall. Boxes and storage containers were on the floor around and behind the TV stand. A case of cup of noodles was on a stack of items at the back corner of the room. Delivery boxes and items were stacked along the entire wall to the left side of the resident; and behind the TV stand, a wheelchair was observed with items stacked on the seat. The bed frame for a potential roommate did not have a mattress on it, and there were belongings stacked on the bed frame. Social Services Staff 2 informed the resident the facility arranged a psychiatry consult for next week, and the resident stated she was glad because she was not doing good and one inch away from a breakdown. The resident stated she was aware that her clutter was an issue, but just thinking about it brought up a lot of emotions and she became overwhelmed. The resident expressed having multiple losses over the past few years and had a difficult time coping. The resident stated she also used online shopping as a coping mechanism and had packages that she had not even opened yet. The resident expressed she was open to meeting with the psychiatrist and hopeful that she could address any issues and work with the facility staff on the clutter and creating safer environment. On 4/28/25 at 0805 hours, an interview was conducted with CNA 9. When asked if Resident 40's clutter got in the way of performing the resident's cares safely, CNA 9 stated it was difficult, but doable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 17 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 2. Review of the facility's P&P titled Electronic Cigarette (e-Cigarette) revised 1/2024 showed the following: Level of Harm - Minimal harm or potential for actual harm - Facility will recognize the residents' rights to use e-Cigarettes; however, this right is strictly in accordance with the interdisciplinary team assessment of a resident's ability to smoke safely, in a designated smoking area. Residents Affected - Few - To promote the safety of the smoking resident, the IDT may require a resident to smoke under direct supervision. Residents are responsible for providing all smoking materials. Such materials will be labeled and maintained in a safe area by facility staff. - E-cigarettes or vaping material(s) for residents requiring supervision will be labeled and kept at the nurses' station. Residents may ask for their vape materials prior to vaping in designated smoking areas. - Residents evaluated by the nurse and reviewed by the IDT as independent through a smoking assessment; and who wish to maintain their own vape materials, may do so only when able to indicate the understanding vape materials are for individual use only and may not be shared with other residents. On 4/21/25 at 1054 hours, an observation and concurrent interview was conducted with Resident 13 in Resident 13's room. Resident 13 stated he would go and use the vape (inhaling aerosol from an electronic cigarette) outside of the facility building and carried his vaping device with him. Resident 13 was observed pulling out a vaping device from a pouch attached to the left side of his wheelchair. Resident 13 stated he kept his vaping device with him, unless he knew he would not be using it, or at nighttime. Medical record review for Resident 13 was initiated on 4/21/25. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 4/4/25, showed Resident 13 had the capacity to understand and make decisions. Review of Resident 13's Smoking Risk assessment dated [DATE], showed Resident 13 was safe to smoke, could light his own cigarette, and did not have any limitations which would impact his ability to smoke. The section for additional information showed Resident 13 was observed using a vape (electronic cigarette). Further review of the medical record for Resident 13 failed to show if Resident 13 was thoroughly assessed and evaluated to determine if he required supervision during smoking and if he could safely store his own smoking materials. On 4/24/25 at 1023 hours, an observation, interview, and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 13 used a nicotine vaping device and would use it independently. LVN 2 stated he kept Resident 13's vaping device in the narcotic drawer when the resident was not using it. LVN 2 stated Resident 13 had his vaping device on him right now, but the resident was not able to keep it with him. LVN 2 stated he needed to ask for the vaping device back from Resident 13. On 4/24/25 at 1328 hours, an interview and concurrent medical record review was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 18 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm DON. The DON verified Resident 13 used an e-cigarette. The DON stated for the residents who smoke, the facility completed a smoking assessment and developed a care plan. The DON verified the Smoking Risk Assessment nor the IDT assessment did not include if Resident 13 was assessed to be able to smoke without supervision or if he could safely store his smoking materials. Residents Affected - Few Cross reference to F656, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 19 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 nursing staff provided the necessary care for one of three final sampled residents (Resident 985) reviewed for indwelling urinary catheter (a flexible tube that drains urine from the bladder) use. * The facility failed to ensure Resident 985's suprapubic indwelling urinary catheter bag was placed below the bladder and covered with a privacy bag. This failure had the potential to result in inadequate care and risk for adverse complications for the residents with an indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Care revised 12/24 showed urinary drainage bags should be maintained in a position to avoid contact with the floor to reduce the risk of developing a urinary tract infection to the extend possible. Urinary drainage bags should be placed in a privacy bag to preserve resident dignity. Medical record review for Resident 985 was initiated on 4/21/25. Resident 985 was admitted to the facility on [DATE]. Review of Resident 985's H&P examination dated 4/19/25, showed the resident had the capacity to understand and make decisions. Review of Resident 985's Order Summary Report for April 2025 showed the following physician's order: - dated 4/18/25, for the suprapubic indwelling catheter 16 FR/10 ml to drainage bag due to the diagnosis of urethral stricture (narrowing of the urethra, the tube connected to the bladder that allows urination). On 4/21/25 at 0946 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with LVN 2. Resident 985's suprapubic indwelling urinary catheter bag was observed placed on the left side of the bed side rail and hanging above the level of Resident 985's bladder. The suprapubic indwelling urinary catheter bag was not covered with a privacy bag. LVN 2 verified the findings and stated the suprapubic indwelling urinary catheter bag should be placed below the resident's bladder. On 4/21/25 at 1000 hours, an interview was conducted with CNA 3. CNA 3 verified she placed Resident 985's suprapubic indwelling urinary catheter bag on the side rail so it did not touch the floor and stated the residents with an indwelling urinary catheters should have the privacy bag. On 4/28/25 at 0925 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 985 had a suprapubic indwelling catheter. The DON stated the indwelling urinary catheter bag should be placed below the bladder to prevent the reflux of urine going back into the bladder and prevent the occurrence of an infection. The DON further stated the indwelling urinary catheter bag should be covered with the privacy bag to ensure the privacy and dignity of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 20 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 resident. Level of Harm - Minimal harm or potential for actual harm On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 21 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to timely respond and follow up on the weight loss for one of four final sampled residents (Resident 169) reviewed for nutrition. In addition, the facility failed to review the resident's nutritional status during the weekly weight management IDT meetings. These failures had the potential for adverse nutritional outcomes and to negatively affect the resident's well-being. Residents Affected - Few Findings: Review of the facility's P&P titled Weight Management revised December 2024 showed the weight management committee, consisting of the key members of the IDT, meets weekly and will include residents who have lost five lbs since their last recorded weight, and a lost of 5% or more of their body weight in the last month. Medical record review for Resident 169 was initiated on 4/22/25. Resident 169 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 169's Order Summary Report showed a physician's order dated 4/21/25, for weekly weights every weekend for four weeks. Review of Resident 169's EHR's Weights and Vitals Summary showed the following weights: - dated 3/17/25, a weight of 218 lbs. - dated 3/31/25, a weight of 187 lbs (a loss of 31 lbs/14.2 % in two weeks). - dated 4/5/25, a weight of 179 lbs (a loss of 29 lbs/17.9 % in 19 days). - dated 4/12/25, a weight of 175 lbs (a loss of 43 lbs/19.7 % in less than one month). Review of the facility's RNA Weekly Weight Monitoring log binders for March and April 2025 showed the following weights for Resident 169: - dated 3/27/25, a weight of 202 lbs (a loss of 16 lbs/ 7.3 % in 10 days). The weight was not recorded in the resident's EHR. - dated 3/30/25, a weight of 201 lbs (a loss of 17 lbs/ 7.8 % in 13 days). The weight was not recorded in the resident's EHR. - dated 4/22/25, the resident's readmission weight of 172 lbs (a loss of 46 lbs/ 21.1 % in five weeks and one day). The weight was not recorded in the resident's EHR. Review of Resident 169's SBAR: Change of Condition assessment dated [DATE], showed the resident had a weight loss of 31 lbs in two weeks, typically consumed more than 51% of most of their meals, and was currently on a diuretic (medication that removes excess body fluid). The assessment showed the physician was notified and no new orders were obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 22 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 169's Nutrition Assessment/Evaluation dated 4/3/25, completed by RD 2 showed the resident's first nutrition evaluation since admission to the facility on 3/16/25. The evaluation showed the resident's weight loss (referring to the resident's 31 lbs weight loss since admission to the facility) and the resident's current weight of 187 lbs. Review of Resident 169's Dietary/Nutritional Progress Note dated 4/17/25 at 1332 hours, completed by RD 1 showed the RD reviewed the resident's weights for 3/17, 3/31, 4/5, and 4/12/25. The RD updated the resident's physician, and the physician was agreeable to adding a Boost VHC (very high caloric) nutritional supplements twice a day. On 4/24/25 at 0823 hours, an interview and concurrent record review was conducted with the DON. The DON stated all the residents were weighed upon admission to the facility, then weekly for four weeks, and then monthly. The DON stated when a resident was readmitted to the facility, the resident should be reweighed upon admission to the facility, and then weekly. The DON stated for the residents who had a weight loss of at least five lbs or five % within 30 days, should be part of the Weight Management IDT meeting. The DON reviewed Resident 169's weights and verified the resident should have been included in the weekly Weight Management IDT meetings due to the resident's weight loss. While reviewing the resident's weights in the resident EHR, the DON was asked about the missing weights. The DON checked the RNA weight logs for each nursing station, and found Resident 169's readmission weights were completed on 3/27 and 4/22/25. The DON verified the resident's weights were not entered in the resident's medical record but should have been. The DON stated the RD and physician should have been notified for the resident's initial weight loss on 3/27/25, and verified the RD and physician were not notified. The DON stated there was a full-time RD and a part-time RD, and the expectation was for the RD to review Resident 169's weight and nutritional status the following workday after the resident's initial weight loss was identified on 3/27/25. On 4/24/25 at 0904 hours, an interview and medical record review was conducted with RD 1, RNAs 1 and 2. RD 1 stated for new admissions, RD 2 usually reviewed the newly admitted residents' nutrition evaluations. RD 1 stated the nutrition evaluation was usually done within seven days after the resident's admission to the facility; however, with Resident 169's weight loss, she should have been evaluated sooner. The RD verified the resident should have been included in the weekly weight management committee meetings. During the interview with RD 1, RNAs 1 and 2 entered the office and both stated the process for obtaining the weights was to document the residents' weight on the weight log after obtaining the resident's weights and provide a copy to the RD. RNAs 1 and 2 further stated for any residents with a weight change of three lbs or more, the RNA would also notify the licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 23 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were performed and documented for two of two final sampled residents (Residents 80 and 143) reviewed for IV management. Residents Affected - Few * The facility failed to ensure the nurse obtained measurements of Resident 143's arm circumference and PICC line external catheter length in accordance with the physician's orders and the facility's P&P. * The facility failed to ensure the arm circumference and external catheter length measurements were measured on admission and during the PICC line change for Resident 80's PICC line. These failures posed the risk for the residents developing complications related to the use of the PICC line. Findings: Review of the facility's P&P titled Assessment of the Patient Receiving IV Therapy dated 2011 showed to measure the external length of the central venous access device and compare to the length documented at insertion, during each dressing change and when catheter dislodgement is suspected. Measure resident's upper arm circumference when clinically indicated to assess the presence of edema and possible deep vein thrombosis. Measure 10 cm above the insertion site. 1. Medical record review for Resident 143 was initiated on 4/21/25. Resident 143 was admitted to the facility on [DATE]. Review of Resident 143's Order Summary Report showed an order dated 2/11/25, to measure the PICC line on admission and after dressing change(s) and arm circumference three inches above the insertion site. Review of Resident 143's Order Summary Report showed an order dated 3/13/25, for daptomycin (antibiotic medication) 450 mg intravenously once a day for sepsis for six weeks. On 4/21/25 at 1025 hours, an observation and concurrent interview was conducted with Resident 143. Resident 143 was observed with a PICC line on her right arm. Resident 143 stated she had an infection after a recent surgery and was currently receiving a course of IV antibiotic therapy via her PICC line. On 4/23/25 at 1138 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked to describe the facility's practice for the resident's PICC line management and assessment. RN 1 stated upon admission to the facility and every 7 (seven) days thereafter, during PICC line dressing changes, the nursing staff would obtain measurements specific to the PICC line. RN 1 stated the nurse would obtain a measurement of the resident's arm circumference and PICC line external catheter length. RN 1 stated the arm circumference measurement was obtained to identify any swelling, which could indicate a deep vein thrombosis. RN 1 stated the external catheter length measurement was obtained to determine if the catheter remained in place. RN 1 stated the PICC line measurements were documented on the resident's IV MAR and/or progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 24 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Review of Resident 143's IV Administration Treatment Records dated 2/2025, 3/2025 and 4/2025 showed documentation Resident 143's PICC line dressing change was performed on the following dates: 2/17, 2/24, 3/3, 3/10, 3/17, 3/24, 3/31, 4/7, 4/14, and 4/21/25. However, further review of Resident 143's medical record failed to show documentation for the measurements of the PICC line external catheter length or Resident 143's arm circumference for these dates. RN 1 verified the findings. Residents Affected - Few On 4/24/25 at 1429 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the findings and stated the facility would update the electronic medical record to allow the nurses to document the PICC line external catheter lengths and the resident's arm circumference. Cross reference to F656, example #1. 2. On 4/21/25 at 0828 hours, during the initial tour of the facility, Resident 80 was observed with a midline catheter to the LUA with the dressing dated 4/17/25. Resident 80 stated he was receiving two different types of antibiotic medications in the facility due to a bone infection to his left foot. Medical record review for Resident 80 was initiated on 4/21/25. Resident 80 was admitted to the facility on [DATE]. Review of Resident 80's admission Body Check dated 3/12/25, showed the resident had a RUA PICC line with two lumens (channels or tubes inside the PICC line). Review of Resident 80's H&P examination dated 3/13/25, showed Resident 80 had the capacity to understand and make decisions. Review of Resident 80's plan of care showed a care plan problem dated 3/21/25, addressing the resident's RUA PICC line. The interventions included to measure the IV lines on admission and after dressing change, and the arm circumference three inches above the insertion site every seven days during the day shift (0700 to 1500 hours). Review of Resident 80's MAR for March and April 2025 showed a physician's order dated 3/13/25, to measure the IV lines on admission and after dressing change, and the arm circumference three inches above the insertion site every seven days during the day shift. The MAR showed the order was discontinued on 4/16/25. Further review of Resident 80's MAR for March and April 2025 showed the licensed nurses signed the MAR; however, the MAR failed to show the measurements of the arm circumference and external catheter length for the PICC line on 3/13, 3/20, 3/27, 4/3, and 4/10/25. Further review of Resident 80's medical record failed to show the baseline measurements of the arm circumference and external catheter length were obtained upon admission to the facility. On 4/23/25 at 0938 hours, an observation and concurrent interview was conducted with Resident 80. Resident 80 was observed with a midline catheter to the LUA. Resident 80 stated he accidentally pulled out the previous IV access on his RUA when he was putting on his sweater sleeve but the IV access was changed to a midline catheter on 4/17/25. On 4/23/25 at 0958 hours, an interview and medical record review was conducted with RN 1. RN 1 verified Resident 80 had a RUA PICC line upon admission to the facility, but it was changed to a midline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 25 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 catheter on 4/17/25. Level of Harm - Minimal harm or potential for actual harm On 4/23/25 at 1108 hours, an interview and medical record review was conducted with the DON. When asked, the DON stated the RNs were responsible to measure and document the arm circumference and external catheter length upon the resident's admission to the facility, then weekly when the resident had a PICC line or a midline catheter. The DON verified Resident 80's MAR for March and April 2025 did not show the measurements of the resident's arm circumference and external catheter length of the PICC line for the above dates. The DON further verified the baseline measurements of Resident 80's RUA PICC line external catheter length and arm circumference were not obtained upon Resident 80's admission to the facility. Residents Affected - Few On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 26 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 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 ensure three of four sampled residents (final sampled residents, Residents 109, 143, and 155) reviewed for respiratory care were provided with the appropriate respiratory care and services when: Residents Affected - Few * The facility failed to ensure Resident 109 received the continuous oxygen therapy via the nasal cannula (flexible tube to deliver oxygen into the nose) as per the physician's order. In addition, the facility failed to ensure the nasal cannula oxygen tubing was not touching the floor mat on the ground. * Resident 143's nebulizer oxygen tubing was improperly stored, having been found lying on top of a sock on the resident's end table. * The facility failed to ensure a physician's order was obtained for Resident 155's use of oral suctioning equipment. Additionally, the facility failed to ensure Resident 155's oral suctioning equipment was labeled when changed. These failures had the potential to affect the respiratory health and well-being of these residents in the facility. Findings: Review of the facility's P&P titled Respiratory Care Oxygen Therapy revised 1/2025 showed the facility provides competent staff to administer oxygen therapy through various types of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheter, oxygen canisters, cylinders, or concentrators. A physician order shall be maintained in the medical record including parameters of oxygen administration and indications for use. The medical record reflects ongoing assessment of the resident's respiratory status and response to oxygen therapy. The staff should document, based on current professional standards of practice, the assessment and monitoring of the resident's respiratory condition, including response to therapy provided, and any changes in the respiratory condition 1. On 4/21/25 at 0852 hours, Resident 109 was observed in bed, with the nasal cannula oxygen tubing inside a clear plastic bag. Resident 109 was not observed receiving the oxygen. Medical record review for Resident 109 was initiated on 4/21/25. Resident 109 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 109 had the diagnosis of acute respiratory failure with hypoxia and acute pulmonary edema. Review of Resident 109's Order Summary Report dated 4/23/25, showed a physician's order dated 3/24/25, to administer continuous oxygen at two to three liters per minute via the nasal cannula, may titrate to maintain SPO2 (peripheral oxygen saturation, a measurement of the amount of oxygen in a person's blood) greater than 91 percent (%) and to monitor and document the oxygen saturation level every shift. Review of Resident 109's plan of care showed a care plan problem dated 3/24/25, addressing Resident 109's episode of desaturation, shortness of breath, and altered level of consciousness on 3/24/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 27 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The interventions included to administer the oxygen continuously at two to three liters per minute via the nasal cannula and to monitor and document the oxygen saturation level every shift. On 4/23/25 at 0846 hours, Resident 109 was observed with the following: - The oxygen nasal cannula was on the right side of Resident 109's bed between the bedrail and the mattress and connected to the oxygen concentrator machine. The oxygen concentrator machine was on and set at two liters per minute; and - The oxygen nasal cannula tubing was observed touching the floor mat on the ground. LVN 5 was observed at the doorway to Resident 109's room, preparing for the morning medication administration. On 4/23/25 at 0918 hours, Resident 109 was observed in bed with the oxygen nasal cannula on the right side of the bed, near the bed rail, and the oxygen nasal cannula tubing was observed touching the floor mat on the ground. On 4/23/25 at 0921 hours, an observation, interview, and concurrent medical record review for Resident 109 was conducted with LVN 5. LVN 5 was observed exiting Resident 109's room and pushing the medication cart to another room. LVN 5 stated she had completed her morning medication administration for the three residents in Resident 109's room, including Resident 109. When asked about Resident 109's oxygen therapy, LVN 5 reviewed Resident 109's medical record and stated Resident 109 was currently receiving continuous oxygen at two to three liters per minute via the nasal cannula. When asked about Resident 109's current oxygen setting, LVN 5 stated she did not check the oxygen setting during the medication administration for Resident 109. LVN 5 verified the above findings. When asked, LVN 5 stated she did not pay attention as to whether Resident 109's nasal cannula was properly on him or if the nasal cannula oxygen tubing was touching the floor mat. LVN 5 was observed replacing the oxygen nasal cannula tubing with a new tubing and placed the new nasal cannula on Resident 109. LVN 5 checked Resident 109's oxygen saturation level and stated his oxygen saturation level was at 88-89%. When asked if LVN 5 could hear the oxygen concentrator machine during the medication administration, LVN 5 stated she was able to hear the oxygen concentrator machine was on, but she did not check to see if the nasal cannula was properly on Resident 109. LVN 5 further stated she should have checked. On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated for the care of a resident on oxygen therapy, the licensed nurses were expected to administer the oxygen as per the physician's order. The DON stated when making rounds and during the administration of medications, the licensed nurse was responsible for checking the placement of the nasal cannula to ensure it was properly placed on the resident. The DON further stated in addition to checking for the proper placement of the oxygen tubing, the licensed nurses were responsible for checking to ensure the oxygen tubing was not touching the ground. On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings. 3. On 4/21/25 at 1436 hours, an observation and concurrent interview was conducted with CNA 4 in Resident 155's room. CNA 4 stated Resident 155 did her own oral care and the licensed nurses would suction her. The oral suctioning equipment, including the Yankauer suction tip, suction tubing, and suction canister were observed not labeled with the date and time it was last changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 28 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/21/25 at 1556 hours, an observation and concurrent interview was conducted with LVN 9 in Resident 155's room. LVN 9 stated Resident 155 performed the oral suctioning by herself and the facility staff changed the canister, tubing, and Yankauer suction tip once a week. The oral suctioning equipment, including the Yankauer suction tip, suction tubing, and suction canister were observed not labeled with the date and time it was last changed. LVN 9 verified the above findings and stated usually the Yankauer suction tip and tubing would be labeled with a date. LVN 9 stated the facility staff replaced the tubing every Sunday; however, LVN 9 verified he did not know when Resident 155's tubing and Yankauer suction tip were last changed. LVN 9 stated the facility staff labeled the tubing with the date it was changed to prevent infections. Medical record review for Resident 155 was initiated on 4/21/25. Resident 155 was readmitted to the facility on [DATE]. Review of Resident 155's H&P examination dated 4/4/25, showed Resident 155 had the capacity to understand and make decisions. Review of Resident 155's Assessment Summary dated 4/4/25, showed the resident's change in condition involving throat congestion. The assessment section showed Resident 155 complained of throat congestion, oral suction was provided as tolerated, and no complaints of nasal congestion. The NP was made aware and ordered STAT chest x-ray, laboratory tests, and an inhaler medication every six hours for shortness of breath. Review of Resident 155's Order Summary Report dated 4/23/25, showed a physician's order dated 4/22/25, to suction orally with the Yankauer suction tip as needed for increased oral secretions/oral care. On 4/22/25 at 1515 hours, an interview was conducted with Resident 155. Resident 155 stated she used the oral suction by herself for excessive phlegm in her throat. On 4/24/25 at 0957 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 155 performed oral care by herself. LVN 1 was informed Resident 155 was observed with the oral suctioning equipment at the bedside since 4/21/25. LVN 1 verified Resident 155 was started on oral suctioning on 4/4/25. LVN 1 stated the resident needed a physician's order for oral suctioning. LVN 1 verified Resident 155 had no physician's order for oral suctioning until 4/22/25. On 4/28/25 at 0851 hours, an interview and concurrent medical record review was conducted with the DON and Nurse Consultant. The DON and Nurse Consultant were informed and acknowledged the above findings. The DON verified Resident 155 had no physician's order for the oral suctioning until 4/22/25. The DON stated the suctioning tubing and canister should be labeled with a date and time and would be changed out weekly, or as needed if soiled. 2. Medical record review for Resident 143 was initiated on 4/21/25. Resident 143 was admitted to the facility on [DATE]. Review of Resident 143's Order Summary Report showed a physician's order dated 2/11/25, to administer ipratropium-Albuterol (medication to relax muscles around the lungs' airways, to ease breathing) inhalation solution 0.5-2.5 mg per 3 ml inhalation solution, every four hours as needed for shortness of breath and/or wheezing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 29 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm On 4/21/25 at 1019 hours, an observation and concurrent interview was conducted with Resident 143 and LVN 3. A nebulizer attached to an oxygen tubing was observed at Resident 143's bedside. The open end of the oxygen tubing was observed lying on top of a sock on Resident 143's end table. Resident 143 stated she had not handled the oxygen tubing. LVN 3 verified the findings and stated she would discard the oxygen tubing for infection control. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 30 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of two final sampled residents (Residents 18 and 69) reviewed for pain management. Residents Affected - Few * The facility failed to accurately document the monitoring of pain for Residents 18 and 69 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Residents 18 and 69 prior to the administration of the pain medications as per the physician's order. These failures had the potential to put Residents 18 and 69 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 1/2025 showed the facility provides pain management to residents who require such services, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Strategies for the prevention and management of pain may include but are not limited to the following: developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both. 1.a. Medical record review for Resident 18 was initiated on 4/21/25. Resident 18 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 18's MDS assessment dated [DATE], showed Resident 18 was cognitively intact and coded for the use of an opioid (narcotic pain medication) medication. Review of Resident 18's Order Summary Report for April 2025 showed the following physician's orders: - dated 6/25/24, to monitor Resident 18's level of pain every shift, using the 0-10 pain scale as follows: 0= no pain, 1-3= mild pain, 4-6= moderate pain, and 7-10= severe pain. - dated 6/25/24, to administer acetaminophen (analgesic medication) 325 mg two tablets by mouth every six hours as needed for mild pain, pain levels of 1 to 3; not to exceed three grams of acetaminophen in 24 hours from all sources. - dated 9/24/24, for the use of Norco (narcotic opioid medication), to document the non-pharmacological approach attempted prior to the administration of pain medication every shift; and to document as follows: 1. Repositioning; 2. Dim Light/Quiet Environment; 3. Hot/Cold Application; 4. Relaxation Techniques; 5. Distraction; 6. Music; 7. Other. - dated 10/28/24, for the use of acetaminophen, to document the non-pharmacological approach attempted prior to the administration of pain medication, every shift; and to document as follows: 1. Repositioning; 2. Dim light/Quiet Environment; 3. Hot/Cold Application; 4. Relaxation techniques; 5. Distraction; 6. Music; 7. Other. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 31 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm - dated 3/31/25, to administer hydrocodone-acetaminophen (narcotic opioid medication) 5-325 mg one tablet by mouth every four hours as needed for moderate pain (pain levels of 4 to 6). - dated 3/31/25, to administer hydrocodone-acetaminophen 5-325 mg two tablets by mouth every four hours as needed for severe pain (pain levels of 7 to 10). Residents Affected - Few Review of Resident 18's plan of care showed a care plan problem dated 6/26/24, addressing Resident 18's risk for pain. The interventions included to administer the acetaminophen and Norco medication as ordered; and to provide the resident with reassurance that pain was time limited; and to encourage the resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultrasound. Review of Resident 18's MAR for April 2025 showed Resident 18 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for moderate pain (pain levels of 4 to 6) on the following dates and times when the resident's pain level was not within the pain levels of 4 to 6 as ordered: - On 4/2/25 at 1047 hours, for a pain level of 8. - On 4/10/25 at 2350 hours, for a pain level of 8. - On 4/22/25 at 0856 and 2109 hours, for a pain level of 8. b. Review of Resident 18's MAR from April 2025 showed Resident 18 was administered the following medications on the following dates, times, and pain levels: * Resident 18's was administered the acetaminophen medication 325 mg two tablets by mouth every six hours as needed for mild pain (pain levels of 1 to 3): - On 4/2/25 at 2300 hours, for a pain level of 3. - On 4/15/25 at 1903 hours, for a pain level of 2. - On 4/16/25 at 2053 hours, for a pain level of 2. * Resident 18 was administered the hydrocodone-acetaminophen medication 5-325 mg one tablet by mouth every four hours as needed for moderate pain (pain levels of 4 to 6): - On 4/6/25 at 0630 hours, for a pain level of 5. - On 4/18/25 at 0945 hours, for a pain level of 4. - On 4/22/25 at 0856 and 2109 hours, for a pain level of 8. However, review of Resident 18's MAR for April 2025 to document the monitoring of the resident's pain level showed the licensed nurses documented Resident 18's pain level was assessed as 0 for no pain for the following dates and shifts: - on 4/2/25, for the night shift; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 32 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 - on 4/6/25, for the night shift; Level of Harm - Minimal harm or potential for actual harm - on 4/15/25, for the evening shift; - on 4/16/25, for the evening shift; Residents Affected - Few - on 4/18/25, for the morning shift; and - on 4/22/25, for the morning and evening shifts. Additionally, further review of Resident 18's MAR for April 2025 showed the non-pharmacological approach attempted prior to the administration of the acetaminophen and Norco pain medications were documented as 0 from 4/1 to 4/22/25 for the day, evening, and night shifts. On 4/23/25 at 1433 hours, an interview and concurrent medical record review for Resident 18 was conducted with LVN 7. LVN 7 stated when pain was reported, the resident's pain would be assessed and the non-pharmacological pain interventions would be implemented and documented in the MAR. LVN 7 stated if the non-pharmacological pain interventions were effective, then the pain medication would not be needed; but if the non-pharmacological pain interventions were not effective, then the pain medication would be administered as per the physician's order and within the ordered parameters. LVN 7 reviewed Resident 18's medical record and verified the above findings. LVN 7 stated if the pain medication was administered, the non-pharmacological intervention should not be documented as 0. On 4/28/25 at 1046 hours, an interview and concurrent medical record review for Resident 18 was conducted with the DON. The DON reviewed Resident 18's medical record and verified the above findings. 2. a. Medical record review for Resident 69 was initiated on 4/21/25. Resident 69 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 69's H&P examination dated 12//23/24, showed Resident 69 had no capacity to understand and make decisions. Review of Resident 69's Order Summary Report for April 2025 showed the following physician's orders: - dated 10/9/23, to monitor Resident 69's level of pain every shift, using the 0-10 pain scale as follows: 0= no pain, 1-3= mild pain, 4-6= moderate pain, and 7-10= severe pain. - dated 12/15/23, for the use of the acetaminophen-codeine (narcotic pain medication), to document the non-pharmacological approach attempted prior to the administration of the pain medication every shift; and to document as follows: 1. Repositioning; 2. Dim Light/Quiet Environment; 3. Hot/Cold Application; 4. Relaxation Techniques; 5. Distraction; 6. Music; and 7. Other. - dated 2/6/25, to administer acetaminophen-codeine 300-30 mg one tablet by mouth every four hours as needed for mild pain, pain levels of 1 to 3; not to exceed three grams of acetaminophen in 24 hours from all sources. Review of Resident 69's plan of care showed a care plan problem dated 10/11/23, addressing Resident 69's risk for pain. The interventions included to administer the acetaminophen with codeine pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 33 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication as ordered and to offer the non-pharmacological interventions for pain (repositioning, dim lighting, calm and quiet environment, minimal stimulation, etc.). Review of Resident 69's MAR for April 2025 showed Resident 69 was administered the acetaminophen-codeine 300-30 mg one tablet by mouth every four hours as needed for mild pain (pain levels of 1 to 3) on the following dates and times when the resident's pain level was not within the pain levels of 1 to 3 as ordered: - On 4/1/25 at 1120 hours, for a pain level of 0. - On 4/7/25 at 1450 hours, for a pain level of 0. - On 4/15/25 at 1130 hours, for a pain level of 0. - On 4/21/25 at 2158 hours, for a pain level of 7. b. Review of Resident 69's MAR for April 2025 showed Resident 69 was administered the acetaminophen-codeine 300-30 mg one tablet by mouth every four hours as needed for mild pain (pain levels of 1 to 3) on the following dates and times: - On 4/2/25 at 0848 hours, for a pain level of 3. - On 4/3/25 at 1336 hours, for a pain level of 3. - On 4/4/25 at 0200 hours, for a pain level of 3. - On 4/5/25 at 0806 hours, for a pain level of 3. - On 4/8/25 at 0438 hours, for a pain level of 3. - On 4/9/25 at 0100 hours, for a pain level of 3. - On 4/10/25 at 1235 hours, for a pain level of 3. - On 4/11/25 at 1338 hours, for a pain level of 3. - On 4/14/25 at 1340 hours, for a pain level of 1. - On 4/16/25 at 0040 and 1251 hours, for a pain level of 3. - On 4/17/25 at 1300 hours, for a pain level of 3. - On 4/19/25 at 1805 hours, for a pain level of 3. - On 4/22/25 at 0200 hours, for a pain level of 3. - On 4/24/25 at 0230 hours, for a pain level of 3. However, review of Resident 69's MAR for April 2025 for the monitoring of the resident's pain level (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 34 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 showed the licensed nurses documented Resident 69's pain level was 0 for no pain for the following dates and shifts: Level of Harm - Minimal harm or potential for actual harm - on 4/2 and 4/3/25, for the day shift; Residents Affected - Few - on 4/4/25. for the night shift; - on 4/5/25, for the day shift; - on 4/8 and 4/9/25; for the night shift; - on 4/10, 4/11, and 4/14/25, for the day shift; - on 4/16/25, for the night shift; - on 4/17/25, for the day shift; - on 4/19/25, for the evening shift; and - on 4/22 and 4/24/25, for the night shift. Additionally, further review of Resident 69's MAR for April 2025 showed the non-pharmacological approach attempted prior to the administration of the acetaminophen-codeine medication was documented as 0 on the following dates and shifts: - for the day shift: on 4/2, 4/3, 4/5, 4/10, 4/14, 4/16, and 4/17/25, - for the evening shift: on 4/19 and 4/21/25, - for the night shift: 4/3, 4/7, 4/8, 4/15, 4/21, and 4/23/25. On 4/24/24 at 1039 hours, an interview and concurrent medical record review for Resident 69 was conducted with LVN 3. LVN 3 stated the non-pharmacological pain interventions were implemented and documented prior to the administration of the pain medications. LVN 3 stated if the non-pharmacological pain interventions were effective, then the pain medication would not be needed. LVN 3 reviewed Resident 69's medical record and verified the above findings. LVN 3 stated the pain medication should be administered as per the physician's order and within the pain parameters. LVN 3 further stated if the pain medication was administered, then the non-pharmacological intervention should be documented. On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated if the pain medication was administered to the resident, the non-pharmacological interventions for pain should be implemented and documented in the MAR; and if the non-pharmacological interventions for pain were ineffective, then the licensed nurse should administer the pain medication as per the physician's orders. The DON stated the purpose of the pain monitoring was to track the resident's pain and to see if there was a trend in the resident's pain. The DON stated the monitoring of pain should be documented accurately. The DON stated if the pain medication was administered to the resident during the shift, then there should be a pain level documented for the monitoring of pain for that shift in the MAR. The DON stated if the resident reported pain after the licensed nurse documented no pain, the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 35 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm expected the licensed nurses to update the pain monitoring for that shift in the MAR to accurately reflect the resident's pain monitoring. On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 36 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 35 sampled residents (Resident 60) and two nonsampled residents (Residents 73 and 685). * The facility failed to ensure Resident 73's omeprazole (acid reflux medication) medication bottle was shaken well prior to administering the medication as per the instruction on the bottle. * The facility failed to ensure the narcotic medication for Residents 60 and 685 were accurately signed out and documented as per the facility's P&P. These failures had the risk for negative health outcomes to the residents and the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber) and unsafe handling of the narcotic medications. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be administered in accordance with the orders. The medications must be administered in accordance with State and Federal guidelines. The P&P further showed the licensed nurse must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility's P&P titled Medication Administration - Controlled Substances revised 1/2023 showed the controlled medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The P&P further showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the flowing information on the accountability record when removing dose from the controlled storage. Administer the controlled medication and document dose administration on the MAR. According to the United States Drug Enforcement Administration (DEA), oxycodone (pain medication) is categorized as a Schedule II narcotic. Tramadol (pain medication) is categorized as a Schedule IV (low potential for abuse) narcotic. The DEA labels these drugs as having a potential for abuse. 1. Medical record review for Resident 73 was initiated on 4/22/25. Resident 73 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 73's H&P examination dated 11/4/24, showed the resident had a history of neurocognitive disorder (group of conditions that primarily affect cognitive abilities like memory, language, and problem solving) and was mostly non-verbal with global weakness (general lack of physical and/or mental strength and fatigue). Review of Resident 73's Order Summary Report for April 2025 showed a physician's order dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 37 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 1/2/25, to administer 10 ml of omeprazole oral suspension two mg/ml via GT one time a day for GERD. Level of Harm - Minimal harm or potential for actual harm Review of Resident 73's omeprazole medication bottle showed the instructions to shake well. Residents Affected - Few On 4/22/25 at 0835 hours, during the medication administration observation, LVN 7 was observed pouring Resident 73's omeprazole into a medication cup. LVN 7 did not shake the bottle well as instructed prior to pouring the omeprazole medication into the medication cup. On 4/22/25 at 0918 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings. LVN 7 verified the omeprazole medication bottle had instructions to shake the bottle well prior to administering. LVN 7 stated the bottle should be shaken well to ensure the concentrate at the bottom of the bottle was distributed. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 2. a. Medical record review for Resident 60 was initiated on 4/22/25. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 60's H&P examination dated 4/15/25, showed the resident had the capacity to make decisions. Review of Resident 60's Order Summary Report for April 2025 showed a physician's order dated 3/2/25, to administer tramadol (opioid medication) 50 mg one tablet by mouth three times a day for pain management; and to hold if the respiratory rate less than 12 breaths per minute. The tramadol medication was scheduled to be administered at 0930, 1530, and 2130 hours. Review of Resident 60's MAR for April 2025 showed the tramadol 50 mg tablet was administered on 4/22/25 at 0930 hours. Review of Resident 60's tramadol narcotic bubble pack showed there was one tablet of tramadol 50 mg medication remaining. However, review of Resident 60's Controlled Drug Record initiated on 4/19/25, showed there should be two tramadol 50 mg tablets remaining instead of one tablet as showed in the bubble pack. On 4/22/25 at 1129 hours, an inspection of the Controlled Drug Record at Medication Cart A was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 stated the narcotic bubble pack and the Controlled Drug Record sheet did not match. LVN 4 stated it should match to ensure the accuracy and to show the medication was administered. On 4/22/25 at 1145 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified the above findings. LVN 10 stated the facility protocol was to sign the Controlled Drug Record and the MAR when administering the narcotic medications, to ensure there were no errors in the narcotic count. b. Medical record review for Resident 685 was initiated on 4/22/25. Resident 685 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 38 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 685's H&P examination dated 4/17/25, showed the resident had no capacity to understand and make decisions. Review of Resident 685's Order Summary Report for April 2025 showed a physician's order dated 4/17/25, to administer oxycodone (opioid medication) 5 mg one tablet by mouth in the morning for pain management, hold for AMS or if the respiratory rate was less than 12 breaths per minute and to notify the physician. Review of Resident 685's MAR for April 2025 showed the oxycodone 5 mg tablet was administered on 4/22/25 at 0900 hours. Review of Resident 685's oxycodone narcotic bubble pack showed there were three tablets of oxycodone 5 mg remaining. However, review of Resident 685's Controlled Drug Record initiated on 4/16/25, showed there should be four oxycodone 5 mg tablets remaining instead of three tablets as showed in the bubble pack. On 4/22/25 at 1359 hours, an inspection of the Controlled Drug Record at Medication Cart B was conducted with LVN 16. LVN 16 verified the above findings. LVN 16 stated the narcotic bubble pack and Controlled Drug Record sheet should match. On 4/28/25 at 1206 hours, and interview with the DON was conducted. The DON stated the facility's expectation was for the licensed nurses to sign the controlled drug sheet once the licensed nurses removed the narcotic medication from the bubble pack and signed the MAR. The DON further stated the licensed nurses must sign out the medication on the controlled drug sheet and MAR to avoid diversion. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 39 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 81) was free from the unnecessary medications. Residents Affected - Few * The facility failed to follow the physician's order to hold the amlodipine, metoprolol, and hydralazine (antihypertensive medications) medications when Residents 81's systolic blood pressure (the top number in a blood pressure measurement) was less than 110 mmHg. This failure had the potential for Resident 81 to develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be administered in accordance with the orders. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's physician's order dated 11/3/24, showed to administer amlodipine 10 mg via GT once a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg. Review of Resident 81's physician's order dated 11/3/24, showed to administer hydralazine 50 mg via GT three times a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg. Review of Resident 81's physician's order dated 11/3/24, showed to administer metoprolol 50 mg via GT two times a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg. Review of Resident 81's Medication Administration Records for 3/2025 and 4/2025 showed the amlodipine 10 mg, hydralazine 50 mg, and metoprolol 50 mg medications were administered by LVN 7, on the following dates/times when Resident 81's systolic blood pressure was less than 110 mmHg: * On 3/14/25 at 0900 hours, the amlodipine 10 mg, metoprolol 50 mg, and hydralazine 50 mg medications were administered when Resident 81's systolic blood pressure was 108 mmHg. * On 4/7/25 at 1300 hours, the hydralazine 50 mg medication was administered when Resident 81's systolic blood pressure was 106 mmHg. * On 4/16/25 at 1300 hours, the hydralazine 50 mg medication was administered when Resident 81's systolic blood pressure was 105 mmHg. On 4/24/25 at 1057 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified she administered the amlodipine 10 mg, metoprolol 50 mg, and hydralazine 50 mg medications on the above listed dates and times when Resident 81's systolic blood pressure was less than 110 mmHg. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 40 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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** 4. a. Medical record review for Resident 56 was initiated on 4/22/25. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's H&P examination dated 11/12/21, showed Resident 56 had no capacity to understand and make decisions. Review of Resident 56's Physician Order Summary Report showed a physician's order dated 4/14/25, to administer seroquel (antipsychotic medication) 50 mg oral tablet by mouth two times a day for psychosis due to dementia (memory loss) manifested by visual hallucination. Review of Resident 56's MAR for April 2025 showed the Seroquel 50 mg medication was administered to the Resident 56. Further review of Resident 56's medical record did not show if the orthostatic blood pressure (when the blood pressure changes from a lying or sitting position to standing) was monitored related to the use of the antipsychotic medication. On 4/24/25 at 1010 hours, an interview and concurrent medical record review for Resident 56 was conducted with LVN 3. LVN 3 stated the orthostatic blood pressure should be monitored for the residents receiving antipsychotic medication. LVN 3 verified Resident 56 received an antipsychotic medication and the orthostatic blood pressure was not monitored related to the use of the antipsychotic medication. b. Review of Resident 56's MAR for April 2025 showed a physician's order dated 1/23/24, to monitor the episodes of psychosis due to dementia manifested by visual hallucination as evidenced by talking to the younger version of her kids related to the use of the Seroquel medication. The MAR further showed the resident had the behavior episodes on the following dates and shifts: - on 4/1/25, during the day, evening and night shifts; - on 4/11/25, during the evening and night shifts; - on 4/13/25, during the evening shift; - on 4/14/25, during the evening and night shifts; - on 4/15/25, during the day and evening shifts; and - on 4/16/25, during the evening shift. Further review of Resident 56's medical record did not show if the non-pharmacological interventions were provided when Resident 56 had the behavior episodes on the above dates and shifts. On 4/24/25 at 1010 hours, an interview and concurrent medical record review for Resident 56 was conducted with LVN 3. LVN 3 verified the behavior episodes on the above dates and shifts for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 41 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 56 and stated she was not able to find the documentation to show if the non-pharmacological interventions were provided for the use of the Seroquel medication. LVN 3 stated when Resident 56 had the behavior episodes related to the use of the Seroquel medication, the non-pharmacological interventions should have been provided. 5. Medical record review for Resident 155 was initiated on 4/23/25. Resident 155 was admitted to the facility on [DATE]. Review of Resident 155's H&P examination dated 4/4/25, showed Resident 155 had the capacity to understand and make decisions. Review of Resident 155's Order Summary Report showed a physician's order dated 4/22/25, to administer alprazolam (antianxiety) 0.25 mg one tablet via GT every 12 hours for anxiety as manifested by inability to relax. Review of Resident 155's MAR for April 2025 showed Resident 155 received the alprazolam medication on 4/22/25 at 2100 hours, and 4/23/25 at 0900 hours. Review of the Resident 155's Psychotherapeutic Medication Informed Consent dated 3/25/25, showed the informed consent was for Xanax (brand name for alprazolam) 0.25 mg half tablet every 12 hours. Further review of Resident 155's medical record failed to show if the informed consent was obtained for the alprazolam 0.25 mg one tablet via GT every 12 hours. On 4/23/25 at 1101 hours, an interview and concurrent medical record review for Resident 155 was conducted with RN 1. RN 1 stated the informed consent should be obtained prior to the administration of the psychotropic medication. RN 1 verified Resident 155's physician's order for the alprazolam tablet 0.25 mg one tablet via GT every 12 hours and stated she was not able to find documented evidence to show if the informed consent was obtained for the alprazolam 0.25 mg one tablet every 12 hours prior to administering the medication to the resident. 6. Medical Record review for Resident 985 was initiated on 4/23/25. Resident 985 was admitted to the facility on [DATE]. Review of Resident 985's POLST dated 4/18/25, showed Resident 985 had the capacity. Review of Resident 985's Order Summary Report showed the following physician's orders dated 4/18/25: - to administer buspirone (antianxiety medication) HCL 5 mg one tablet via GT two times a day for anxiety as manifested by restlessness. - to administer venlafaxine (antidepressant medication) HCL 150 mg extended release 24-hour one capsule via GT every 12 hours for depression as manifested by verbalization of sad feelings. Review of the Resident 985's MAR dated 4/1-4/30/25, showed Resident 985 was administered the buspirone medication on 4/19, 4/20, 4/21, and 4/22/25 at 0900 and 1700 hours, and 4/23/25 at 0900 hours. Further review of the MAR showed Resident 985 was administered the venlafaxine medication on 4/19, 4/20, 4/21, and 4/22/25 at 0900 and 2100 hours, and 4/23/25 at 0900 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 42 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident 985's medical record failed to show if the informed consent was obtained for the above medications prior to the administration of the medications. On 4/23/25 at 1101 hours, an interview and concurrent medical record review for Resident 155 was conducted with RN 1. RN 1 verified Resident 985's physician's orders for the buspirone and venlafaxine medications. RN 1 stated she was not able to find documented evidence to show if the informed consent was obtained for the above medications for Resident 985. RN 1 stated the informed consent should have been obtained for the use of the buspirone and venlafaxine medications before administering the medications to Resident 985. On 4/25/25 at 0908 hours, an interview and concurrent medical record review was conducted for Residents 56, 155 and 985 with the DON. The DON verified and acknowledged the above findings. 3. Medical record review for Resident 9 was initiated on 4/21/25. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 4/10/24, showed the resident had the capacity to understand and make decisions. Review of Resident 9's Order Summary Report for April 2025 showed a physician's order dated 4/14/25, to administer trazodone 50 mg (depression medication) two tablets by mouth at bedtime for depression manifested by poor sleep. Review of Resident 9's MAR for April 2025 showed Resident 9 was administered the trazadone 100 mg at 2100 hours from 4/14 to 4/22/25. Review of Resident 9's Psychotherapy Medication Informed Consent form for the trazadone 100 mg medication dated 4/14/25, showed no documented evidence Resident 9's physician had signed or dated the informed consent for the use of the trazadone medication. On 4/23/25 at 0949 hours, an interview and concurrent medical record review was conducted with LVN 14. LVN 14 verified the above findings. LVN 14 stated Resident 9's informed consent for the trazadone medication should have been signed and dated by the physician since the medication dosage was increased. LVN 14 verified there was no documented evidence the physician had signed and dated the informed consent for Resident 9's trazadone medication. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure six of seven final sampled residents (Residents 9, 56, 69, 135, 155, and 985) reviewed for the unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 69's orthostatic blood pressure was monitored for the use of the quetiapine (antipsychotic) medication as per the care plan. In addition, the facility failed to implement the non-pharmacological interventions for Resident 69's observed behaviors for the use of the quetiapine and sertraline (antidepressant) medications. * The facility failed to ensure Resident 135's orthostatic blood pressure was accurately monitored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 43 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as ordered by the physician and per the care plan, for the use of the olanzapine (antipsychotic) medication. In addition, the facility failed to implement the non-pharmacological interventions for Resident 135's use of the olanzapine, lorazepam (antianxiety), and citalopram (antidepressant) medications. * The facility failed to ensure Resident 135's informed consent for the olazapine medication showed who gave the consent for the medication. * The facility failed to ensure Resident 9's informed consent for the trazadone medication was signed and dated by the physician. * The facility failed to ensure the orthostatic blood pressure was monitored related to the use of the Seroquel (antipsychotic medication) medication for Resident 56. In addition, the facility failed to ensure the non-pharmacological interventions were implemented for the psychotic behaviors exhibited by Resident 56. * The facility failed to ensure the informed consent was obtained prior to administering the alprazolam (antianxiety) medication when the dose of the medication was increased from 0.25 mg one-half tablet to one tablet for Resident 155. * The facility failed to ensure the informed consent was obtained prior to administering the venlafaxine (antidepressant medication) and buspirone (antianxiety medication) medications for Resident 958. These failures had the potential for these residents to receive unnecessary psychotropic medication and to not be informed of the medication and potential effects of psychotropic medications. Findings: Review of the facility's P&P title Dignity and Respect Psychoactive Drugs dated 1/2025 showed the residents who use psychotropic drugs shall receive gradual dose reduction and behavioral interventions, unless contraindicated, in an effort to discontinue these drugs. The practitioner shall determine that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication (s). The facility will monitor for adverse side effects associated with the use of psychotropic medications. The use of non-pharmacological approaches shall be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. Under the section Resident's Right to be informed, prior to initiating or increasing psychoactive medication, the Resident, family, and/or Resident representative shall be informed of the benefits, risks, and alternatives for the medication, including any black box warning for antipsychotic medication, in advance of such initiation or increase. Further review of the P&P showed the resident's medical record shall include documentation that the resident or resident representative was informed in advance of the risk and benefits of the proposed care, the treatment alternative that he or she preferred. The facility has a written consent form which may serve as evidence of a resident's consent to psychotropic medication; and may have other documented evidence of the resident's consent or decline to treatment 1. Medical record review for Resident 69 was initiated on 4/21/25. Resident 69 was admitted to the facility on [DATE], and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 44 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of Resident 69's H&P examination dated 12/23/24, showed Resident 69 had no capacity to understand and make decisions. Review of Resident 69's Order Summary Report dated 4/24/25, showed the following physician's orders for the use of the quetiapine medication: Residents Affected - Few - dated 12/11/23, to document the non-pharmacological approach attempted prior to the administration of the quetiapine medication; and to document: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other, every shift; - dated 1/9/24, for the use of the quetiapine medication, to monitor the episodes of psychosis manifested striking out and tally with hashmarks every shift; and - dated 4/10/25, to administer quetiapine 25 mg one tablet by mouth three times a day for psychosis manifested by striking out. Review of Resident 69's Order Summary Report dated 4/24/25, showed the following physician's orders for the use of the sertraline medication: - dated 12/15/23, to document the non-pharmacological approach attempted prior to the administration of the sertraline medication. To document: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other, every shift; - dated 1/5/25, to administer sertraline 100 mg one tablet by mouth daily for depression manifested by uncontrollable crying, and - dated 4/19/25, for the use of the sertraline medication, to monitor the episodes of depression manifested by uncontrollable crying and tally with hashmarks every shift. Review of Resident 69's plan of care showed the following care plans: - dated 10/11/23, addressing Resident 69's use of the quetiapine medication. The interventions included to monitor for orthostatic hypotension, to obtain the blood pressure readings while lying and sitting weekly and to call the physician when changes were noted; and to use non-pharmacological approaches: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other as needed; and - dated 10/11/23, addressing Resident 69's use of the sertraline medication. The interventions included to use non-pharmacological approaches: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 45 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other as needed. Review of Resident 69's MAR for April 2025 showed Resident 69 was administered quetiapine 25 mg one tablet by mouth three times a day and sertraline 100 mg one tablet by mouth daily. Residents Affected - Few Further review of Resident 69's MAR for April 2025 showed the following: * Resident 69 had the episodes of psychosis behaviors manifested by striking out for the usage of the quetiapine medication as follows: - on 4/4/25, two episodes during the day shift, - on 4/5/25, three episodes during the day shift, - on 4/6/25, two episodes during the day and evening shifts, - on 4/7/25, four episodes during the day and evening shifts, and three episodes during the night shift, - on 4/8/25 three episodes during the day shift and four episodes during the evening shift, - on 4/9/25, five episodes during the day and evening shifts, and three episodes during the night shift, - on 4/10/25, two episodes during the day and night shifts, and three episodes during the evening shift. - on 4/11/25, three episodes during the day shift, - on 4/16/25, two episodes during the day, evening, and night shifts, - on 4/17/25, four episodes during the day shift, and - on 4/19/25, 10 episodes during the day shift and five episodes during the night shift. * Resident 69 had the episodes of depression manifested by uncontrollable crying for the usage of the sertraline medication as follows: - on 4/2/25, seven episodes during the day shift and six episodes during the evening shift. - on 4/3/25, nine episodes during the day shift, - on 4/5/25, 10 episodes during the day shift and seven episodes during the evening shift, - on 4/6/25, four episodes during the day shift, - on 4/9/25, four episodes during the day shift and evening shift, and three episodes during the night shift, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 46 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 - on 4/15/25, two episodes during the day shift, Level of Harm - Minimal harm or potential for actual harm - on 4/16/25, six episodes during the day shift and evening shift, - on 4/17/25, seven episodes on the day shift and two episodes on the evening and night shift, Residents Affected - Few - on 4/18/25, four episodes during the day shift, - on 4/19/25, seven episodes during the days shift, and - on 4/20/25, 11 episodes during the day shift. Further review of the MAR showed the non-pharmacological approaches attempted prior to the administration of the quetiapine and sertraline medications were documented as 0 for the above documented behavioral episodes. Review of Resident 69's medical record failed to show a physician's order to monitor Resident 69 for orthostatic hypotension. The medical record also failed to show the care plan intervention was implemented for Resident 69's orthostatic blood pressures monitoring related to Resident 69's use of the quetiapine medication. Additionally, Resident 69's medical record failed to show documented evidence the non-pharmacological interventions were implemented when Resident 69 exhibited the monitored behaviors for the use of the sertraline and quetiapine medication. On 4/24/25 at 1011 hours, an interview and concurrent medical record review for Resident 69 was conducted with LVN 3. LVN 3 stated for the residents who were prescribed the antipsychotic medications, the orthostatic blood pressures should be monitored and documented in the medical record. LVN 3 stated when the licensed nurse did not see an order for the monitoring of orthostatic hypotension for the residents with prescribed antipsychotic medication, the licensed nurse should clarify the order with the physician. LVN 3 stated the residents on any psychotropic medications were monitored for the behavior every shift. LVN 3 stated when the residents were observed with the exhibiting behaviors, the non-pharmacological interventions should be implemented and documented. LVN 3 reviewed Resident 69's medical record and verified the above findings. 2.a. Medical record review for Resident 135 was initiated on 4/21/25. Resident 135 was admitted to the facility on [DATE], with the diagnoses of unspecified psychosis and major depressive disorder. Review of Resident 135's H&P examination dated 7/18/24, showed Resident 135 had no capacity to understand and make decisions. Review of Resident 135's Order Summary Report dated 4/23/25, showed the following physician's orders for the use of the olanzapine medication dated 7/18/24: - to administer olanzapine 10 mg one tablet by mouth at bedtime for psychosis manifested by sudden angry outburst, - to monitor for orthostatic hypotension for the use of the olanzapine medication, to obtain the blood pressure while lying and sitting every seven days, on the day shift, - for the use of the olanzapine medication, to monitor the episodes of psychosis manifested by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 47 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 sudden angry outburst, every shift, and Level of Harm - Minimal harm or potential for actual harm - to document the nonpharmacological approach attempted prior to the administration of the olanzapine medication; and to document: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other, every shift. Residents Affected - Few Review of Resident 135's plan of care showed the following care plans: - dated 7/19/24, addressing the black box warning for Resident 135's use of the olanzapine medication. The interventions included monitoring for orthostatic hypotension, to obtain the blood pressure readings while standing/lying and sitting weekly and to call the physician when changes were noted. - dated 7/24/24, addressing Resident 135's use of the olanzapine medication. The interventions showed to use non-pharmacological approaches: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other as needed. Review of Resident 135's MAR for April 2025 showed the following orthostatic blood pressure readings: - on 4/7/25, the blood pressure readings were documented as 122/62 mmHg for the lying and sitting positions, - on 4/14/25, the blood pressure readings were documented as 124/68 mmHg for the lying and sitting positions, and - on 4/21/25, the blood pressure readings were documented as 126/62 mmHg for the lying and sitting positions. Further review of Resident 135's MAR for April 2025 showed Resident 135 had the episodes of psychosis manifested by sudden angry outburst for the usage of the olanzapine medication on the following dates: - on 4/1/25, two episodes during the day and evening shifts, - on 4/2/25, eight episodes during the day shift and one episode during the evening shift, - on 4/3/25, eight episodes during the day shift, -on 4/4/25, five episodes during the day shift, - on 4/5/25, seven episodes during the day shift and one episode during the evening shift, - on 4/8/25, eight episodes during the day shift, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 48 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 - on 4/9/25, six episodes during the day shift, Level of Harm - Minimal harm or potential for actual harm - on 4/10/25, four episodes during the day shift, - on 4/11/25, five episodes during the day shift, Residents Affected - Few - on 4/14/25, six episodes during the day shift, - on 4/15/25, two episodes during the day shift and 10 episodes during the night shift, - on 4/16/25, six episodes during the day shift, four episodes during the evening shift, and eight episodes during the night shift, - on 4/17/25, six episodes during the morning shift and three episodes during the evening shift, - on 4/19/25, six episodes during the day shift and one episode during the evening shift, and - on 4/22/25, six episodes during the day and evening shifts. However, review of Resident 135's MAR for April 2025 showed the non-pharmacological approached attempted for the olanzapine medication was documented as 0 for the above documented behavioral episodes. b. Review of Resident 135's Psychotherapeutic Medication Informed Consent for the olanzapine 10 mg medication showed a verbal consent was obtained by phone on 1/16/25. However, further review of the informed consent failed to show who gave the consent for the olanzapine medication. Under the signature of the representative section showed, verbal consent, and the section for the name and relationship to the resident was left blank. c. Review of Resident 135's Order Summary Report dated 4/23/25, showed the following physician's orders for the use of the citalopram medication: - dated 7/18/24, for the use of the citalopram medication, to monitor the episodes of depression manifested by tearfulness every shift; - dated 7/18/24, to document the non-pharmacological approach attempted prior to the administration of the citalopram medication, and to document: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other, every shift; and - dated 12/29/24, to administer citalopram 20 mg one tablet by mouth two times a day for depression manifested by tearfulness. Review of Resident 135's plan of care showed the following care plan: - dated 7/24/24, addressing Resident 135's use of the citalopram medication. The interventions showed to use non-pharmacological approaches: 1. Encourage to verbalize feelings (needs/concern), 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 49 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other as needed. Review of Resident 135's MAR for April 2025 showed the following: Residents Affected - Few * Resident 135 had the episodes of depression manifested by the tearfulness for the usage of the citalopram medication on the following dates: - on 4/2 and 4/3/25, two episodes during the day shift, - on 4/4/25, two episodes during the evening shift, - on 4/5/25, one episode during the evening shift, - on 4/7/25, three episodes during the day shift, - on 4/9/25, two episodes during the day shift, - on 4/11 and 4/12/25, one episode during the evening shifts, - on 4/14 and 4/15/25, two episodes during the day shifts, - on 4/17/25, two episodes during the evening shift, - on 4/19 and 4/20/25, one episode during the evening shift, - on 4/21/25, two episodes during the day shift and one episode during the evening shift, and - on 4/22/25, two episodes during the day shift, and one episode during the evening and night shifts. However, review of Resident 135's MAR for April 2025 showed the non-pharmacological approached attempted prior to the administration of the citalopram medication was documented as 0 for the above documented behavioral episodes. c. Review of Resident 135's Order Summary Report dated 4/23/25, showed the following physician's orders for the use of the lorazepam (anti-anxiety) medication: - dated 3/20/25, to document the non-pharmacological approach attempted prior to the administration of the lorazepam medication, and to document: 1. Encourage to verbalize feelings (needs/concern), 2. Encourage family to participate in care, 3. Encourage to attend daily activities, 4. Provide a quiet and calm environment with diversion like listening to music/watching TV, 5. Teach the resident relaxation techniques or deep breathing exercises, 6. Redirect and provide gentle reality orientation, 7. Other, every shift; and - dated 4/20/25, to administer lorazepam 0.5 mg one tablet by mouth every eight hours as needed for anxiety manifested by agitation, yelling with no apparent reason for 30 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 50 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of Resident 135's MAR for April 2025 showed Resident 135 was administered lorazepam (antianxiety medication) 0.5 mg one tablet by mouth every eight hours as needed for anxiety manifested by agitation, yelling with no apparent reason on the following dates and times: - on 4/4/25 at 1020 hours, Residents Affected - Few - on 4/5/25 at 2000 hours, - on 4/6/25 at 1800 hours, - on 4/7/25 at 2213 hours, - on 4/8/25 at 1249 hours, - on 4/10/25 at 1900 hours, - on 4/13/25 at 1240 hours, - on 4/14/25 at 1028 hours, and - on 4/21/25 at 1138 hours. However, review of Resident 135's MAR showed the non-pharmacological approached attempted prior to the administration of the lorazepam medication was documented as 0 for the above dates. On 4/23/25 at 1456 hours, an interview and concurrent medical record review for Resident 135 was conducted with LVN 7. LVN 7 stated for the residents prescribed with the psychotropic medication, the consent was obtained by the physician and reviewed by the licensed nurses. LVN 7 stated the consent should be completed to include the name of the drug, dose, behavior manifestations, and the person who consented. LVN 7 further stated for the residents prescribed with the antipsychotic medication, there should be a physician's order to monitor for the orthostatic hypotension. LVN 7 stated the process to monitor for the orthostatic hypotension was to obtain the resident's blood pressure in two different positions and the blood pressure readings were compared to determine if there was a drop in the blood pressure. LVN 7 reviewed Resident 135's medical record and verified the above findings. LVN 7 stated the informed consent for the olanzapine medication was incomplete and should indicate the name of the person who consented for the antipsychotic medication. LVN 7 further stated the orthostatic blood pressure readings (lying and sitting positions) should not be the same. On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated for the residents prescribed with the antipsychotic medication, the informed consent should include the resident's name, medication ordered, targeted behaviors, and drug category. The DON stated the informed consent should have the physician's signature and signature of the person consenting for the medication. The DON stated for the verbal consents, the informed consent should show who the verbal consent was obtained from. The DON further stated prior to the administration of the psychotropic medication, the informed consent should be complete and include the above information. The DON stated for the residents on the antipsychotic medication, the resident should be monitored for the orthostatic hypotension. The DON stated the process to monitor for the orthostatic hypotension was for the licensed nurse to obtain the resident's blood pressure reading in two different positions. The DON stated after obtaining the blood pressure readings in two different positions, the licensed nurse was expected to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 51 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few compare the blood pressure reading to determine if there was a drop in the blood pressure, which could indicate orthostatic hypotension. The DON stated the blood pressure readings for each position should not be the same. The DON stated the residents were monitored for the behaviors related to psychotropic medication usage every shift. The DON stated if the behavior was observed, the licensed nurse was expected to implement and document the non-pharmacological interventions rendered and should not document as 0 (zero). On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 52 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/22/25 at 1132 hours, during the inspection of Medication Room B with LVN 7, the following was observed: - two collection swabs with the expiration date of 11/30/22, - one administration set with the expiration date of 1/7/25, - two scabies collection kits with the expiration date of 1/13/25, - one 23 g injection needle with three ml syringe with the expiration date of 3/31/25, - one 4 ml vacutainer with the expiration date of 11/30/24, - one 6 ml vacutainer with the expiration date of 1/31/25, - one 8 ml vacutainer with the expiration date of 12/31/24, and - one 8 ml vacutainer with the expiration date of 3/31/25. LVN 7 verified the above findings and stated the expired supplies should be removed from the medication room. 4. Review of the facility document titled Ophthalmic Medication Beyond-Use Date Guide dated 4/2024 showed the expiration date for the latanoprost (glaucoma medication) solution 0.005% was 42 days after opening. On 4/22/25 at 1419 hours, during the inspection of Medication Cart C with LVN 8, the following medications was observed: - one opened bottle of latanoprost 0.005% eye drops for Resident 95, labeled 2/12/25 (69 days from the opened date). - one opened bottle of latanoprost 0.005% eye drops for Resident 95 was not labeled with an opened date. - one opened bottle of latanoprost 0.005% eye drops for Resident 81 was not labeled with an opened date. LVN 8 verified the above findings. LVN 8 stated the eye drop medications should be labeled with the opened date when the medication was first opened to determine the discard date. LVN 8 further stated the eye drops should be discarded after 28 days after opening. 5. On 4/24/25 at 0753 hours, an inspection of Medication Cart F was conducted with LVN 11 and the following was observed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 53 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm - one opened packet of type 1 bovine collagen powder (wound filler dressing) labeled with the opened date of 4/18/25. The instructions on the packet showed to not use if the package was opened or damaged. Do not reuse. Sterile unless package was opened or damaged. - one opened and cut hydrofera blue (antibacterial foam) dressing. Residents Affected - Few LVN 11 verified the above findings. On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated all eye drop medications should be labeled with the opened date to determine the discard date. The DON stated the licensed nurses were responsible for checking the medication rooms weekly and expected to remove the expired supplies during the weekly inspection. The DON stated the licensed nurses assigned to the medication carts were responsible for the storage of medications inside the medication cart and should ensure the medications inside the medication carts were labeled properly with the opened date and removed from the medications carts when expired. The DON stated the collagen powder was for single use and should not be kept once opened. The DON added the hydrofera blue dressing should be sterile and it was for one-time use. The DON stated the unused portion of the collagen powder and hydrofera blue dressing should be discarded. On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings 7. On 4/21/25 at 0816 hours, during the initial tour of the facility, a bottle of Refresh Relieva eye drop was observed on the resident's cabinet. On 4/21/25 at 0839 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above findings and stated Resident 785 was unable to administer the eye drop independently. Medical record review for Resident 785 was initiated on 4/21/25. Resident 785 was admitted to the facility on [DATE]. Review of Resident 785's H&P examination dated 4/17/25, showed the resident had no capacity to understand or make decisions. Review of Resident 785's Order Summary Report dated 4/22/25, showed a physician's order dated 4/21/25, to administer one drop of Refresh Optive Advanced PF (lubricant eye drop) ophthalmic solution to both eyes every six hours as needed for dry eyes. However, further review of Resident 785's physician's orders failed to show the physician's orders for the use of the Refresh Relieva eye drop and/or to store the medication at the bedside prior to 4/21/25. On 4/22/25 at 1419 hours, an interview and concurrent medical record review for Resident 785 was conducted with LVN 1. LVN 1 verified there was no physician's orders for the use of the Refresh Relieva eye drop and/or to store the medication at the bedside prior to 4/21/25. LVN 1 stated he notified Resident 785's physician on 4/21/25, to obtain the physician's order for the Refresh Relieva eye drop, after he verified the resident was observed with the eye drop at the bedside. On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 54 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 above findings. Level of Harm - Minimal harm or potential for actual harm 6.a. On 4/21/25 at 0859 hours, a concurrent observation of Refrigerator B and interview was conducted with the Activities Director in Dining Room B. A bottle of Norwegian fish oil supplement medication was observed in the refrigerator labeled with an open date of 11/2/24. There was no resident name or room number on the bottle. The Activities Director verified the findings. Residents Affected - Few Medical record review for Resident 136 was initiated on 4/21/25. Resident 136 was admitted to the facility on [DATE]. Review of Resident 136's Order Summary Report dated 4/23/25, showed a physician's order dated 9/24/25, for ½ (half) teaspoon of Norwegian Omega 3s via GT in the morning for supplement, in fridge, and the family provided. b. On 4/22/25 at 1112 hours, a concurrent observation of Refrigerator B and interview was conducted with the Activities Assistant in Dining Room B. An unlabeled bottle of Norwegian fish oil supplement medication was observed in Refrigerator B. The Activities Assistant then asked LVN 10 about the fish oil and verified the Norwegian fish oil bottle medication was for Resident 136's. On 4/22/25 at 1115 hours, a concurrent interview and medical record review was conducted with LVN 10. LVN 10 stated Resident 136's daughter brought in the Norwegian fish oil medication and the LVNs had been providing Resident 136 the fish oil every morning since November. LVN 10 verified the physician's order for the Norwegian fish oil. LVN 10 verified the Norwegian fish oil was a medication and should be stored in the medication room. On 4/24/25 at 1345 hours, an interview was conducted with the DON. The DON stated the fish oil was a medication, should be stored in the medication room, and should be labeled with the resident's name, date opened, and directions for use. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following: * The facility failed to ensure the oral and suppository medications in Medication Cart D were stored separately. * The facility failed to ensure the opened and expired medications and medical supplies in Medication Cart E were properly disposed. * The facility failed to ensure the expired medical supplies were removed from Medication Room B. * The facility failed to ensure Resident 81 and 95's latanoprost 0.005% (glaucoma medication) eye drops were labeled with the opened date; and failed to discard Resident 95's latanoprost 0.005% eyedrop after the beyond-use by date in Medication Cart C. * The facility failed to ensure the opened collagen powder and opened hydrofera blue (antibacterial foam) dressing were discarded after opening in Medication Cart F. * The facility failed to ensure Resident 136's Norwegian fish oil was stored safely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 55 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure Resident 785's Refresh Relieva (lubricant eye drop) eye drop was not stored at the bedside. These failures had the potential to negatively impact the residents' well-being and the potential for the medications to lose the stability and effectiveness. Residents Affected - Few Findings: Review of the facility's P&P titled Labeling of Biologicals and Storage of Biologicals revised 3/2022 showed the facility will provide accurate labeling to facilitate precautions and safe administration of medications, and safe and secure storage. The P&P also showed drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary infections, and the expiration date when applicable. 1. On 4/22/25 at 1129 hours, an inspection of Medication Cart D and concurrent interview was conducted with LVN 4. LVN 4 verified the following medications were stored together: - six acetaminophen 650 mg (pain medication) suppositories; - three bisacodyl laxative 10 mg (stool softener medication) suppositories; and - eight ondansetron ODT (orally dissolving tablet) 4 mg (nausea and vomiting medication) tablets LVN 4 stated the oral and suppository medications should not be stored together. LVN 4 stated the medications were organized based on the route for the medication to be administered to ensure the oral and suppository medications were not mixed up. 2. On 4/22/25 at 1346 hours, an inspection of Medication Cart E and concurrent interview was conducted with RN 2. The following medical supplies and medications were observed: - one 0.9 % sodium chloride (normal saline) syringe was opened ; - one bandage roll was opened; - two sterile gloves were opened; and - two IV secondary administration sets had expired on 8/12/24. RN 2 verified the findings and stated the expired items should be discarded to ensure the integrity of the medical supply. RN 2 also stated the 0.9% sodium chloride syringe, the bandage, and the sterile gloves should have been closed to ensure the medication and medical supplies were not used and kept sterile. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 56 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 45 of 171 residents who received food from the kitchen received the proper diets when the facility's menu was not followed. * The facility failed to ensure 45 residents who were on CCHO diets (diets for diabetics) and three residents who were on renal diets (specialized diet designed to support kidney health) received the homemade barbeque (BBQ) sauce with their oven BBQ beef roast as per the menu and recipe. This failure had the potential for the residents' nutritional needs not being met, which could result in medical complications. Findings: Review of the Diet Order Tally Report dated 4/21/25, showed 171 of 182 residents received food from the kitchen. Review of the Diet Order Tally Report - All Special Diets dated 4/21/25, showed 45 residents were on CCHO diets and three residents were on renal diets. Review of the facility's P&P titled Menus revised 9/2021 showed the facility provides meals to the residents that meet requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. Food served should adhere to the written menu. Review of the facility's document titled Spring Cycle Menus, Week 4 Wednesday dated 4/23/25, showed the beef roast for the CCHO and renal diets was to be served with the homemade BBQ sauce. Review of the facility document titled Recipe: Oven BBQ Beef Roast Week 4 Wednesday dated 2024 showed the following recipe for the special diets: - For the renal diets, to make with low sodium BBQ sauce or homemade BBQ sauce; and - For the CCHO diets, to make with homemade BBQ sauce. Review of the facility document titled Recipe: Homemade BBQ sauce dated 2025 showed a recipe for BBQ sauce and to use as indicated with other recipes and spreadsheets. On 4/23/25 at 1133 hours, during the lunch tray line observation, [NAME] 1 was observed to have served the prepared beef roast for all the therapeutic diets with the same BBQ sauce. On 4/23/25 at 1254 hours, an observation and concurrent interview was conducted with the DSS and [NAME] 1. The DSS stated the facility used a bottled BBQ sauce for the beef roast. The DSS and [NAME] 1 verified the same bottled BBQ sauce was used for all of the therapeutic diets and there was no homemade BBQ sauce. On 4/8/25 at 1200 hours, an interview was conducted with RD 1. RD 1 was informed of the above findings. RD 1 stated the kitchen staff should be following the recipes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 57 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. On 4/21/25 at 0908 hours, an observation of Resident 19's private refrigerator and concurrent interview was conducted with CNA 3. There was an unopened package of turkey breast deli meat with a use by date of 5/13/23, stored inside the refrigerator. CNA 3 verified the turkey breast was kept past the used by date. 10. On 4/21/25 at 0928 hours, an observation of Resident 986's private refrigerator and concurrent interview was conducted with LVN 2. There was an undated and unlabeled resealable bag of noodles stored inside the refrigerator. LVN 2 verified the bag of noodles was not dated and labeled. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen and resident food storage areas. * The facility failed to ensure the resident carafes were air dried. * The facility failed to ensure the food in the cold and dry storage areas were labeled, dated, and the expired items were thrown out. * The facility failed to ensure the food preparation equipment was clean and free from damage. * The facility failed to ensure the freezer in Refrigerator A, located in Dining Room A and Refrigerator B, located in Dining Room B were monitored for the temperatures and recorded in the temperature log. * The facility failed to ensure the resident's food items in Refrigerators A and B were properly labeled and dated. Additionally, the resident's food items of Resident 13 and 735's personal refrigerators were not properly labeled and dated. * The facility failed to ensure the temperature of the personal refrigerator for Resident 13 was at or below 41 degrees F. * The facility failed to ensure the dishwasher's chlorine concentration met the minimum concentration of 50 ppm. * The facility failed to ensure the quaternary sanitizer test paper was not expired. * Resident 19 had expired deli sandwich meat in the resident's private refrigerator. * Resident 986 had undated food items in the resident's private refrigerator. These failures had the potential to expose the residents who received food from the kitchen to foodborne illnesses. Findings: Review of the Diet Order Tally Report dated 4/21/25, showed 171 of 182 residents received food from the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 58 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's P&P titled Use And Storage of Food Brought To Resident revised March 2023 showed the food brought to the residents will be stored for no more than 48 hours, must be labeled with the resident's name, dated, and ensure it is used by the use by date. 1. According to the USDA Food Code 2022 Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried. On 4/21/25 at 0801 hours, during an initial tour of the kitchen with the DSS, resident plastic carafes were observed stored on top of a sheet pan on a clean storage rack. Four of the resident carafes were observed with condensation on the inside. The DSS verified the finding and stated the kitchen staff would usually have a netting underneath to air dry. 2. Review of the facility's P&P titled Labeling and Dating of Foods dated 2020 showed all the food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows the guidelines. On 4/21/25 at 0805 hours, during an initial tour of the kitchen and concurrent interview with the DSS, the following was observed: - Six containers of diced peaches had the use by dates of 4/19 and 4/20 in Refrigerator C. The DSS verified the items had expired and removed them from the refrigerator. - A bin of thickener was undated in the dry storage area. - A bin of brown rice was undated in the dry storage area. - 10 heads of lettuce were wilted with brown areas in the Refrigerator D. - One bottle of cranberry juice cocktail was without a use by date in Refrigerator D. - One bottle of chocolate flavored syrup was without a use by date in Refrigerator D. - One opened bag of wafer cookies was undated in the dry storage room. - One bag of cherry gelatin mix was without a use by date in the dry storage room. - One bag of potato chips was without a use by date in the dry storage room. The DSS verified the findings. 3. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Sanitation dated 2018 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, crack and chipped areas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 59 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. On 4/21/25 at 0823 hours, during an initial tour of the kitchen and concurrent interview with the DSS, the following was observed: - The can opener blade was observed with brown and yellow residue. - The kitchen microwave was observed with yellow stains on the top wall and yellow residues on the bottom wall. The DSS verified the above findings. b. On 4/23/25 at 0905 hours, an observation and concurrent interview was conducted with LVN 11 in the Station A utility room. The resident's microwave was observed to have an orange and black stain on the inside corner back wall, with chipped areas. LVN 11 stated the housekeeping staff would clean the microwave. On 4/28/25 at 1119 hours, an observation and concurrent interview was conducted with the Maintenance Director in the Station A utility room. The resident's microwave was observed to have an orange and black stain on the inside corner back wall, with chipped areas. The Maintenance Director started to scrape the back wall of the microwave and stated it was a liquid burn that damaged the coating. The Maintenance Director stated he would take the microwave out and bring another one. 4. Review of the facility's P&P titled Refrigerator/Freezer Temperature Records revised 7/2016 showed a daily temperature record is to be kept for refrigerated and frozen storage areas. The freezer temperature must be zero degrees F or below. a. On 4/21/25 at 0838 hours, an observation and concurrent interview was conducted with LVN 15 in Dining Room A for Refrigerator A. LVN 15 was asked about the temperature log for the freezer. LVN 15 verified there were food items in the freezer, however, there was no freezer temperature log. b. On 4/21/25 at 0859 hours, an observation and concurrent interview was conducted with the Activities Director in Dining Room B for Refrigerator B. The Activities Director verified there were food items in the freezer; however, there was no freezer temperature log. On 4/21/25 at 0916 hours, an observation and concurrent interview was conducted with Housekeeping 1, translated by CNA 7, in Dining Room B. Housekeeping 1 stated she would clean Refrigerator B and would check the temperatures everyday. Housekeeping 1 stated she checked the freezer temperature; however, she would only document the refrigerator temperature. Housekeeping 1 verified the facility did not have a freezer temperature log. On 4/21/25 at 0937 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the findings. The Maintenance Director stated the facility staff did not check the freezer temperatures for the refrigerators in Dining Rooms A and B . 5. Review of the facility's P&P titled Use and Storage of Food Brought to Resident revised 3/2023 showed to ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to resident's by family and visitors for a period not to exceed 48 hours. Perishable foods must be stored in the refrigerator .containers will be labeled with the resident's name, and the manufacturer use-by date as applicable. Labeling, dating, and monitoring refrigerated food, including leftovers, so it is used by its use-by date or frozen or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 60 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discarded in accordance with acceptable standards of safe food storage guidelines, shall be the responsibility of the designated facility staff. a. On 4/21/25 at 0838 hours, an observation and concurrent interview was conducted with LVN 15 in Dining Room A for Refrigerator A. On the side of the refrigerator was a sign posted showing All items in the refrigerator must be labeled and dated; Label must say resident's name, room number, and dated; Any foods without label or dates will be discarded; Any food stored longer than three days will be discarded. LVN 15 stated the activities staff was responsible to check for the expired food. The following was observed: - Two bags of bread without a name or date; - One [NAME] drink with a straw inside it, unlabeled; - One round cake in a container, unlabeled; and - One food container with liquid for Resident A dated 4/17. LVN 15 verified the above findings On 4/21/25 at 0855 hours, an observation and concurrent interview was conducted with the Activities Director in Dining Room A for Refrigerator A. The Activities Director stated their responsibility for the resident's refrigerators were to check the temperature logs and together with the housekeeping staff, would check the food for a label and if the food items were older than three days. The Activities Director stated she would label the food with the room number, name, and date the food came in. The Activities Director stated Resident A's food should have been thrown out the day prior. b. On 4/21/25 at 0859 hours, an observation and concurrent interview was conducted with the Activities Director in Dining Room B for Refrigerator B. The following was observed and verified with the Activities Director: - One opened and one unopened Breyers chocolate ice cream, unlabeled; - One opened bottle of cranberry juice dated 4/8/25; - One yogurt with a best by date of 4/5/25; - One opened bottle of apple sauce dated 4/2/25; - One bag with illegible writing containing prepared food items; - One opened black forest ham package for Resident 40 dated 3/19/25; and - One opened cheese tray for Resident 40 dated 3/19/25. The Activities Director stated she needed to re-inservice the facility staff to talk to the residents' family members about labeling of the food items. c. On 4/21/25 at 1054 hours, an observation and concurrent interview was conducted with Resident 13 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 61 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in his room. Resident 13's personal refrigerator was observed with food items, including bottled sauces, cartons of milk, and packaged cheeses, which were unlabeled. On 4/21/25 at 1604 hours, an observation and concurrent interview was conducted with RN 3 in Resident 13's room. RN 3 opened Resident 13's personal refrigerator and verified Resident 13's food items were not labeled. d. On 4/21/25 at 1522 hours, an observation and concurrent interview was conducted with Resident 735 in her room. Resident 735's personal refrigerator was observed with five covered food containers from the kitchen, unlabeled. Resident 735 stated she refrigerated her soups from the kitchen. On 4/21/25 at 1609 hours, an observation and concurrent interview was conducted with RN 3 in Resident 735's room. RN 3 opened Resident 13's personal refrigerator and verified the food items were unlabeled. 6. Review of the facility's P&P titled Refrigerator/Freezer Temperature Records revised 7/2016 showed the refrigerator temperature must be 41 degrees F or below. On 4/21/25 at 1054 hours, an observation and concurrent interview was conducted with Resident 13 in his room. Resident 13's personal refrigerator's thermometer was observed to read 52 degrees F. Resident 13 stated he might need a new thermometer. The refrigerator was observed with food items, including sauces, covered items from the kitchen, cartons of milk, and packaged cheeses. On 4/21/25 at 1604 hours, an observation and concurrent interview was conducted with RN 3 in Resident 13's room. RN 3 opened Resident 13's personal refrigerator and verified the thermometer read 48 degrees F. RN 3 stated she did not know what the refrigerator temperature should be. On 4/21/25 at 1615 hours, an interview was conducted with LVN 2 and RN 3. LVN 2 stated the resident refrigerator needed to be less than 40 degrees F. LVN 2 stated he would need to throw out the items in the refrigerators with the out-of range temperature. On 4/28/25 at 1119 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated the housekeeping staff checked the temperatures of the personal refrigerators daily. The Maintenance Director stated if the temperatures were out of range, he would replace the thermometer or would need to fix the refrigerator. The Maintenance Director was informed of the above findings. The Maintenance Director then went to Resident 13's room, opened the personal refrigerator, and checked the temperature. The temperature was observed to be 50 degrees F. The Maintenance Director stated he would need to get a new thermometer and Resident 13 left the refrigerator door open frequently. 7. Review of the facility's P&P titled Dishwashing dated 2018 showed for a low temperature machine, the chlorine should read 50-100 ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing dishes. If you do not achieve the proper temperature or chlorine level, resort to the manual method of dishwashing. On 4/22/25 at 0909 hours, an observation of the facility's dishwashing machine was conducted with Dietary Aide 1 with translation by the Dietary Assistant Supervisor. Dietary Aide 3 was observed clearing dishes on the dirty side, Dietary Aide 1 was observed placing the dishes in the dishwasher, and Dietary Aide 2 was observed on the clean side, putting the dishes away. Several cycles of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 62 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dishwashing were observed, and Dietary Aide 2 was observed to put dish domes, trays, and plates away. Dietary Aide 1 was asked how he checked if the machine was working and demonstrated how he checked the sanitizer solution. Dietary Aide 1 stated the solution should test at 50-100 ppm. The test strip was observed to have a lighter color than 50 ppm (the sanitizer solution concentration did not reach 50 ppm). The Dietary Assistant Supervisor then tested the sanitizer solution and verified the sanitizer solution concentration was lower than 50 ppm. The DSS stated she would call the Dishwasher Company. The Dietary Assistant Supervisor stated the kitchen staff would stop the dishwashing and wait for the Dishwasher Company to come. On 4/22/25 at 0956 hours, a follow-up interview was conducted with the DSS. The DSS stated for the dishes which were already washed, they would have to re-run the dishes through the dishwasher once the Dishwasher Company Employee came. On 4/22/25 at 1106 hours, the Dishwasher Company Employee was observed finishing the repair of the facility's dishwashing machine. The Dishwasher Company Employee verified the dishwashing machine was fixed and stated he needed to change the chlorine sanitizer solution line. 8. On 4/23/25 at 1518 hours, an observation and concurrent interview was conducted with Dietary Aide 4 and the DSS regarding the changing out and testing for the quaternary ammonium sanitizer solution used for their red buckets. The Quat-10 test paper used to test the sanitizer solution showed an expiration date of 11/1/24. The DSS verified the Quat-10 test paper was expired and brought new Quat-10 test paper to Dietary Aide 4. The DSS stated using the expired test strips, the reading could be wrong. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 63 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and family/visitors who brought food for the residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources. Residents Affected - Few Findings: Review of the facility's P&P titled Use and Storage of Food Brought to Resident revised 3/2023 showed the facility has procedures to ensure safe and sanitary storage, handling, and consumption of the foods brought to the residents by the family and other visitors. The facility strives to support each resident's right to safe food storage, handling, and preparation. To ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to the residents by the family and visitors for a period not to exceed 48 hours, and in accordance with the following guidelines. The facility helps the family and visitors to understand safe food handling practices. On 4/21/25 at 1230 hours, an observation and concurrent interview was conducted with Resident 88 in her room. Resident 88's personal refrigerator was observed to contain several foil-covered plates. On 4/23/25 at 0910 hours, an observation and concurrent interview was conducted with CNA 5. CNA 5 stated the facility stored the residents' food in the dining room refrigerator. CNA 5 stated she reheated the food in the residents' microwave. When asked how she reheated the food, CNA 5 stated the resident would tell her how long they wanted the food to be microwaved. CNA 5 stated the facility had a thermometer in the utility room to check the temperatures of the reheated food; however, when the utility room microwave was checked with CNA 5, there was no thermometer observed. On 4/23/25 at 0912 hours, an interview was conducted with LVN 12. LVN 12 stated the safe food handling included to make sure the food did not burn the resident when the food was very hot. When asked what she educated the family members regarding the safe food handling, LVN 12 stated the food had to be thrown out within a three-day period, so the resident would not get sick from eating the old food. LVN 12 was unable to recall if she received any in-service education regarding the safe food handling. On 4/23/25 at 0926 hours, an interview was conducted with CNA 6. CNA 6 stated the safe food handling included hand washing and labeling the food with a name and date. CNA 6 stated if a family member brought in food for a resident, he would not tell the family member anything and would let the resident eat the food. On 4/23/25 at 0929 hours, an interview was conducted with LVN 13. LVN 13 stated if she reheated food for a resident, she would ask how hot they wanted the food, re-heated the food, then checked with the resident if the food was warm enough. LVN 13 stated she was not sure if she had been educated regarding the safe food handling. On 4/23/25 at 0934 hours, an interview was conducted with LVN 14. LVN 14 verified there were residents who had family members bring in food from the outside. LVN 14 stated the facility would check the food to make sure it was aligned with the resident's diet and would inform the next shift about the food. LVN 14 stated the facility staff would inform the family member that the facility would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 64 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 storing the food for two days. LVN 14 stated she had not been educated regarding the safe food handling. Level of Harm - Minimal harm or potential for actual harm On 4/23/25 at 0942 hours, an interview was conducted with the Admissions Designee. The Admissions Designee stated on the admission, the admissions staff would educate the family members to make sure they talked with the nursing staff about the food from the outside and if it aligned with the resident's diet. The Admissions Designee stated the admissiona staff provided the facility's policy titled Use and Storage of Food Brought to Resident in the facility's admission packet and verified the admissions staff did not provide information specific to the safe food handling. Residents Affected - Few On 4/23/25 at 1000 hours, an interview was conducted with the DSD. The DSD stated the safe food handling included having the CNAs sanitize their hands and for the licensed nurses to check on the meals before it was sent out to the resident. The DSD stated when she provided the in-services to the facility staff, she would instruct the facility staff to label and date the food item and to endorse to the next shift if the resident wanted to eat it at the following mealtime. When asked if she provided education specific to the safe food handling to the facility staff, the DSD stated she had not educated the facility staff about the safe food handling. On 4/23/25 at 1013 hours, an interview was conducted with RD 1. RD 1 stated she had not provided education to the nursing staff regarding the safe food handling. RD 1 stated she did not educate everyone who brought in food and could not guarantee they had the safe food handling practices. On 4/23/25 at 1435 hours, an interview was conducted with Family Member 1. Family Member 1 stated she had brought Resident 88 a traditional lamb dish for Easter Sunday. Family Member 1 stated she had not been educated by the facility regarding the safe food handling and stated the facility did not instruct her regarding bringing in food from the outside. On 4/28/25 at 1450 hours, an interview was conducted with the Administrator, DON, ADON, Nurse Consultant, RD 1, and DSS. The Administrator, DON, ADON, Nurse Consultant, RD 1, and DSS acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 65 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to properly dispose of the discarded cardboard boxes. This failure had the potential to attract rodents and pests that carried a disease. Residents Affected - Some Findings: Review of the facility's P&P titled Dispose of Garbage And Refuse revised March 2023 showed the facility will properly dispose of the garbage and refuse, waste will be contained in dumpsters or bins with lids to prevent harboring of pests. On 4/25/25 at 0940 hours, an observation and concurrent interview was conducted with the Maintenance Director. A pile of broken-down and flattened cardboard boxes and a stack of carboard boxes were observed on the ground against the building. The Maintenance Director stated the discarded boxes were stored there to be picked up weekly. The Maintenance Director verified the discarded boxes were not placed in a container with a lid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 66 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility's P&P titled Medical Record Content revised 5/2019 showed the purpose of the policy is to ensure adequate and accurate documentation of care provided to each resident while at the facility. The Procedure section showed the medical record will be accurate, timely, and complete and may include the MAR and TAR. Medical record review for Resident 80 was initiated on 4/21/25. Resident 80 was admitted to the facility on [DATE]. Review of Resident 80's IV MAR for March 2025 showed the following entries had missing documentation from the licensed nurses on 3/14/25, for the day shift: - for IV line order #2 (blood return check, then flush with 10 ml of normal saline before and after medication administration every shift); - for IV line order #3 (flush to remain accessed and blood return check, then flushed with five ml of normal saline followed by 3 ml of Heparin (anticoagulant) 10 unit per ml before and after medication administration every shift); and - for IV line order #5 (to monitor IV line and observe for reactions during infusion. Observe for signs and symptoms of infiltration or phlebitis (inflammation of the vein) before and after medication administration. Further review of Resident 80's IV MAR for March 2025 showed the following entries had missing documentation from the licensed nurses: - dated 3/25/25, to administer daptomycin (antibiotic) 750 mg intravenously every 24 hours (at 1600 hours) for left foot osteomyelitis (bone infection) for four weeks; and - dated 3/30 and 3/31/25, to administer ertapenem (antibiotic) 1 gram intravenously every 24 hours (at 2200 hours) for left foot osteomyelitis for four weeks. On 4/23/25 at 0958 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the IV MAR should be signed by the licensed nurses after administering the medications and completing the physician's orders. On 4/23/25 at 1108 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. On 4/24/25 at 1352 hours, an interview was conducted with the Administrator, ADON, DON, and Nurse Consultant. The Administrator, ADON, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Medical record review for Resident 163 was initiated on 4/21/25. Resident 163 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 67 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of Resident 163's H&P examination dated 3/24/25, showed the resident had no capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm Review of Resident 163's admission Record showed Resident 163 had a GT. Residents Affected - Few Review of Resident 163's Order Summary Report for April 2025 showed the following physician's orders: - dated 3/21/25, for NPO diet, NPO texture, NPO consistency; - dated 3/21/25, to administer senna 8.6 mg (stool softener) one tablet by mouth every 12 hours as needed; - dated 3/25/25, to administer vitamin D3 125 mcg (supplement) one tablet by mouth one time a day; - dated 4/13/25, to administer ferrous sulfate 325 mg (supplement) one tablet by mouth two times a day; - dated 4/13/25, to administer vitamin C 500 mg (supplement) by mouth in the morning; - dated 4/16/25, for aspiration precaution every shift; - dated 4/19/25, to administer Decadron 2 mg (inflammation medication) by mouth two times a day for one day, then give one mg by mouth two times a day for two days, then give one mg by mouth one time a day for two days then give 0.5 mg by mouth one time a day for two days for anemia (condition where the blood does not carry enough oxygen to the body's tissues). On 4/24/25 at 0925 hours, an interview and concurrent medical record review was conducted with LVN 16. LVN 16 verified the above findings. LVN 16 stated Resident 163 did not receive the medications or food by mouth and was NPO. LVN 16 further stated Resident 163's medication orders were not accurate and the route of medication administration should be via GT. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 2. Medical record review for Resident 56 was initiated on 4/22/25. Resident 56 was admitted to the facility on [DATE]. Review of the Resident 56's Physician Order Summary Report showed a physician order dated 2/26/24, for hydralazine (medication to lower the blood pressure), to monitor the blood pressure every eight hours and to give hydralazine as needed if the systolic blood pressure more than 150 mmHg. Review of Resident 56's MAR from 4/1/25 to 4/22/25, showed on 4/6, 4/7, 4/8, 4/9, and 4/18/25 at 1400 hours, failed to show documented evidence Resident 56's blood pressure was monitored. Further review of the MAR showed the resident's blood pressure readings of 128/74 mmHg on 4/22/25 at 0600 and 1400 hours. Review of Resident 56's medical record did not show documented evidence to explain why the resident's blood pressure was not monitored on 4/6, 4/7, 4/8, 4/9, and 4/18/25, as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 68 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/22/25 at 1444 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings and stated she was not able to find documentation showing why the blood pressure was not monitored for Resident 56 on the above dates and time. LVN 7 stated on 4/22/25 at 1400 hours, Resident 56 refused the blood pressure monitoring; however, LVN 7 verified she documented the blood pressure for Resident 56 as 128/74 mmHg. LVN 7 stated she made a mistake and copied the blood pressure from the previous shift. LVN 7 stated she did not accurately document the blood pressure reading for Resident 56. LVN 7 further stated she should have documented accurately when Resident 56 refused the blood pressure monitoring. On 4/25/25 at 0908 hours, an interview and concurrent medical record review for Residents 56 was conducted with the DON. The DON verified and acknowledged the above findings. 5. Review of the facility's P&P titled Medical Record Content revised 5/2019 showed the facility will maintain an accurate medical record to facilitate continuity of care among health care providers by ensuring adequate and accurate documentation of care provided. The medical record will be accurate, timely and complete and may include consultant reports and physician progress notes. Medical record review for Resident 40 was initiated on 4/17/25. Resident 40 was readmitted to the facility on [DATE]. Review of Resident 40's Order Summary Report showed a physician's order dated 5/8/22, for a psychiatry evaluation and follow-up as needed. Review of Resident 40's Care Plan Report showed on 9/26/24, the resident was seen by a psychiatrist. Further review of the Resident 40's medical record failed to show the consultant psychiatrist's consult note. On 4/28/25 at 1318 hours, an interview and concurrent record review was conducted with the DON. The DON stated she was unable to locate the consultant psychiatrist's progress note in the resident's records. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for four of 35 final sampled residents (Residents 56, 80, 81, and 163) and one nonsampled resident (Resident 40). * Resident 81 had conflicting orders for holding Resident 81's enteral feeding via GT, specific to the residuals. * The facility failed to ensure the accurate and complete medical record for Resident 56. * The facility failed to ensure the medication routes for Resident 163 with GT were accurate. * The facility failed to ensure the documentation on the IV MAR was completed for Resident 80. * Resident 40's consult psychiatrist's progress note was not part of the resident's medical record. These failures had the potential for not providing necessary care and services due to inaccurate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 69 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 medical records. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few 1. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's physician's order dated 11/3/24, showed to provide Glucerna (enteral feed type) 1.5 by enteral feeding pump (via GT) at a rate of 60 ml/hr for 20 hours. Review of Resident 81's physician's order dated 11/3/24, showed to check and record the enteral feeding (gastric) residuals every shift and to hold the feeding one hour for residual greater than 100 ml. Review of Resident 81's physician's order dated 11/8/24, showed to check the GT feeding (gastric) residuals every six hours and to hold the feeding for two hours if the residual greater or equal to 500 ml. On 4/24/25 at 1235 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 81 had conflicting orders for holding Resident 81's enteral feeding, specific to gastric residuals. The DON stated the order needed to be clarified with Resident 81's physician to ensure the enteral feeding was administered in accordance with the appropriate gastric residual hold parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 70 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 4/25/25 at 0954 hours, an inspection of the facility's clean laundry room was conducted with the Maintenance Director and the Laundry Aide. The following were observed in the clean linen area: Residents Affected - Few - Staff's personal jacket and backpack were hanging on a hook next to the dryer, hanging over a bin of clean linen. - Staff's personal cell phone and a plastic water bottle were sitting on the clean linen folding table, in contact with the clean linen. - Staff's personal keys and keyring were on the table next to a pile of clean resident clothing. - A container of Sani-clean disinfectant wipes was on the table touching a pile of clean resident clothing. - Staff's plastic water bottle was on a pile of clean resident blankets in a clean laundry bin. The Maintenance Director and Laundry Aide verified the above findings and stated the personal belongings and disinfectant wipes should not be near the clean linen areas. 5. Medical record review for Resident 985 was initiated on 4/21/25. Resident 985 was admitted to the facility on [DATE]. Review of Resident 985's Order Summary Report showed a physician's order dated 4/21/25, for contact isolation for MDRO in the urine. On 4/21/25 at 1205 hours, an observation of Resident 985's room and interview was conducted with LVN 2. LVN 2 verified the resident was in contact isolation for the MDRO, and the trash receptacle in the resident's room did not have a lid, and it should. On 4/23/25 at 1441 hours, an interview was conducted with the IP. The IP stated for the residents on an isolation precautions for an active MDRO, they should have a trash bin with a lid. The IP verified Resident 985 had an active MDRO and should have a trash bin with a lid in their room. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for two of 35 final sampled residents (Residents 143 and 985) and one nonsampled resident (Resident 37) as evidence by the following: * The facility failed to ensure the EBP was maintained for Resident 143 with a PICC line during an IV medication administration observation. * The facility failed to ensure the visitors wore PPE in a contact isolation room for Resident 985. * During the medication administration observation for Resident 37, LVN 6 failed to perform hand hygiene in between glove use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 71 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few * The clean laundry room had the facility staff's personal belongings and a Sani-cloth disinfectant wipe container with the clean linen. * Resident 985's did not have a trash bin with a lid in their room, when the resident had a MDRO. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions revised 4/2024 showed Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of multidrug-resistant organism (MDRO) colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and wounds or presence of unhealed pressure ulcers. The P&P further showed indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities such as device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. According to the CDC's Transmission-Based Precaution - Infection Control Basics dated 4/2024 showed contact precautions are used for residents with known or suspected infections that represent an increased risk for contact transmission. Furthermore, use of PPE includes gloves and gown for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens. 1. Medical record review for Resident 143 was initiated on 4/21/25. Resident 143 was admitted to the facility on [DATE]. Review of Resident 143's Order Summary Report for April 2025 showed the following physician orders: - dated 3/13/25, to administer daptomycin (antibiotic medication) 450 mg intravenously once a day for sepsis for six weeks. - dated 2/11/25, to change the central line cap every seven days and as needed or after blood draws. Further review of Resident 143's Order Summary Report for April 2025 showed no documented evidence of a physician's order for the EBP. On 4/23/25 at 0905 hours, during the IV medication administration observation, RN 1 was observed administering the IV medication for Resident 143 via a PICC line to the resident's right upper arm. RN 1 was observed administering the IV medication with gloves on but without a gown. Furthermore, an observation outside of Resident 143's room showed no evidence an EBP signage was posted outside the resident's room. On 4/23/25 at 0918 hours, an interview was conducted with RN 1. RN 1 verified the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 72 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RN 1 also verified Resident 143 had a PICC to the right upper arm. RN 1 stated the residents with the PICC lines, GT, indwelling urinary catheters, wounds or colostomy were placed on EBP. RN 1 stated for EBP, the PPE included donning of the gown and gloves. RN 1 further stated there should be a physician's order for the EBP and an EBP signage should be posted outside of the resident's room. 2. Medical record review for Resident 985 was initiated on 4/21/25. Resident 985 was admitted to the facility on [DATE]. Review of Resident 985's H&P examination dated 4/19/25, showed the resident had the capacity to understand and make decisions. Review of Resident 985's Order Summary Report for April 2025 showed the following physician orders: - dated 4/21/25, for contact isolation related to the diagnosis of MDRO Serratia (type of bacterial infection) in the urine every shift until 4/26/25. - dated 4/18/25, for suprapubic indwelling urinary catheter size 16 FR/10 ml to drainage bag due to the diagnosis of urethral stricture. Review of Resident 985's Care Plan Report dated 4/24/25, showed a care plan problem addressing the resident's isolation contact precautions related to UTI Serratia in the urine. The interventions included to maintain a contact precautions as indicated and to provide instructions and/or education to the resident, family, visitor, and facility staff regarding the contact precaution, proper use of the PPE when in direct contact with the resident and the materials needed and used by the resident. On 4/24/25 at 0958 hours, Family Member 3 was observed sitting at the bedside without wearing PPE (gloves and gown). Family Member 3 verified he did not wear the PPE upon entering the room. On 4/24/25 at 1019 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 985 was on contact isolation and the visitors should wear their PPE while in the room for infection control and to protect the transmission of the infection. LVN 2 further stated the contact isolation PPE included wearing the gown and gloves. On 4/28/25 at 0925 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the PPE, including gloves and gown and mask as needed, was worn in a contact isolation room to prevent the spread of germs through direct or indirect contact with the resident or their environment. The DON further stated the PPE was required for the facility staff and visitors. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Personal Protective Equipment revised 9/2023 showed hands are washed before and after removing of gloves. Medical record review for Resident 37 was initiated on 4/22/25. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Order Summary Report for April 2025 showed a physician's order dated 4/25/24, to implement enhanced barrier precautions due to the indwelling urinary catheter medical device (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 73 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 usage, every shift. Level of Harm - Minimal harm or potential for actual harm On 4/22/25 at 0901 hours, a medication administration observation was conducted with LVN 6 for Resident 37. Residents Affected - Few LVN 6 was observed preparing the following medications: - one tablet of metformin (diabetic medication) 1000 mg, - one tablet of enteric-coated aspirin (antiplatelet medication) 81 mg, - one tablet of Januvia (diabetic medication) 100 mg, - one tablet of multivitamin with mineral (supplement) - 30 ml of LiquaCell-protein, and - one bottle of olopatadine 0.7% (to treat allergic conjunctivitis) eyedrop. LVN 6 was observed donning gloves and entered Resident 37's room to administer the medications. After administering Resident 37's oral medications, LVN 6 was observed removing her gloves and donned a new pair of gloves. LVN 6 was not observed performing hand hygiene. LVN 6 then made contact with Resident 37 and administered a drop of the olopatadine 0.7% eye drop into Resident 37's right eye. LVN 6 then removed her gloves and donned a new pair of gloves. LVN 6 was not observed performing hand hygiene. LVN 6 then administered a drop of the olopatadine 0.7% eye drop medication into Resident 37's left eye. On 4/22/25 at 0917 hours, a concurrent observation and interview was conducted with LVN 6. LVN 6 verified the sign posted on Resident 37's room door showed to adhere to EBP for the residents in Beds A and C (Resident 37 was in bed C). LVN 6 stated Resident 37 was on enhanced barrier precautions for her indwelling urinary catheter. LVN 6 was asked about the process for the administration of the eye drops. LVN 6 stated when administering the eye drop medication for both eyes, separate gloves should be worn to prevent cross contamination. LVN 6 stated after removing the gloves, hand hygiene should be performed prior to donning a new pair of gloves. LVN 6 verified she did not perform hand hygiene between the glove use during the medication administration observation. On 4/23/25 at 1103 hours, an interview was conducted with the IP. The IP stated the facility staff should don gown and gloves when anticipating coming in close contact with a resident who was on EBP. The IP stated during the medication administration process, when a licensed nurse transitioned from administering oral medications to administering eye drops, the licensed nurse should doff the gloves, wash hands or perform hand hygiene, and then don a new pair of gloves. The IP further stated when administering eye drops for both eyes, the licensed nurse should doff gloves, perform hand hygiene and don a new pair of gloves, after administering the eye drop to one eye to prevent cross contamination. On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 74 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm 2. Review of the facility document titled Assure Platinum Blood Glucose Monitoring System: Quality Control Record for April 2025 for Medication Cart B, showed the serial number was 1040-4306369. Residents Affected - Few However, an inspection of the glucometer in use for Medication Cart B showed the serial number was 1040-4436257. On 4/22/25 at 1421 hours, an inspection of the glucometer in Medication Cart B was conducted with LVN 4. LVN 4 verified the serial numbers for the glucometer in use and the quality control record for Medication Cart B did not match. 3. Review of the facility document titled Assure Platinum Blood Glucose Monitoring System: Quality Control Record for April 2025 and the glucometers for Medication Carts A and B showed the quality control checks were not performed from 4/16 to 4/22/25. LVN 4 stated the quality control checks should be performed to ensure the glucometer readings for the residents' blood sugars were accurate. On 4/28/25 at 0925 hours, an interview was conducted with the DON. The DON stated the serial numbers on the glucometer and the Quality Control Record should match. The DON also stated the glucometers were calibrated to ensure for an accurate blood sugar readings when the glucometers were used on the residents. On 4/28/25 at 1443 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. Based on observation, interview, and facility document review, the facility failed to ensure the facility equipment was maintained in the safe operating condition. * For Medication Cart C, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. In addition, the facility failed to ensure the corrective actions were taken when the quality control results for the glucometer were out of range. * The facility failed to ensure the serial number on the glucometer and on the Quality Control Record matched for Medication Cart B. * The facility failed to ensure the quality control checks were performed for the glucometers in Medication Cart A and B. These failures had the potential risk of inaccuracy for the residents' blood glucose test results. Findings: Review of the Assure Platinum (blood glucose monitoring system), User Instruction Manual (undated) showed to perform control solution tests in accordance with the state regulatory guidelines. To use the Assure Dose Control Solutions to check if: the meter and test strips are working correctly as a system, and you are testing correctly. There are two levels of control solution: Normal and High. Under the section for Performing a Control Solution Test showed to compare the result to the range printed on the test strip bottle. To make sure the result is within the acceptable range. If the result (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 75 of 76 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 555733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Sunny Hills 2222 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few falls within this range, the meter and test strip are working correctly. Do not use the system if the control solution result is out of range. For professionals: to record the result in the quality logbook. Do not use the system to test the blood glucose until the control solution result is within the range. 1. On 4/22/25 at 1419 hours, an inspection of Medication Cart C, interview, and concurrent facility document review was conducted with LVN 8. Inspection of the medication cart showed the glucometer currently in use with the serial number of 1040-4428884. However, review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for April 2025 for the glucometer for Medication Cart C showed the serial number of the glucometer was 1040-4209664 which did not match the serial number of the glucometer observed in Medication Cart C. Further review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for April 2025 for Medication Cart C showed the following recorded control results: - dated 4/2/25, the high control range was recorded as 209-261 mg/dL. The high control result showed 348 mg/dL, and the corrective action was recorded as 0; and - dated 4/17/25, the high control range was recorded as 212- 264 mg/dL. The high control result showed 359 mg/dL, and the corrective action was recorded as 0. LVN 8 verified the above findings. LVN 8 stated if the quality control result was out of range, a corrective action should have been completed. On 4/28/25 at 1046 hours, an interview was conducted with the DON. The DON stated the purpose of quality control test for the glucometer was to ensure the glucometer was working effectively to provide accurate results when checking the residents' blood sugar. The DON stated the quality control for the glucometers were conducted daily, during the night shift. The DON stated the serial number on the glucometer device should match the serial number documented on the quality control log. The DON stated if the control reading result was out of range, the licensed nurse should recheck and perform the quality control test again. The DON stated if the result was still out of range, another glucometer should be used. The DON further stated if the result was out of range, she expected a corrective action to be documented. On 4/28/25 at 1440 hours, the Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555733 If continuation sheet Page 76 of 76