Health inspection·March 23, 2023

F 0623 Level of Harm - Potential for minimal harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and medical record review, the facility failed to provide notices of discharges for two of three closed record sampled residents (Residents 20 and 21) as evidenced by: Residents Affected - Some * A copy of the discharge notice for Resident 21 was not sent to a representative of the Office of the State Long-Term Care Ombudsman. * The contact information about the Developmental Disabilities Agency was not provided to Resident 20's responsible party. These failures had the potential for the residents' not receiving full protection during their transfer processes. Findings: 1. On 3/23/23, closed medical record review was initiated for Resident 21. Resident 21 was discharged from the facility on 2/8/23. Review of Resident 21's closed medical record showed a copy of the discharge notice for Resident 21 was not sent to a representative of the Office of the State Long-Term Care Ombudsman. 2. On 3/23/23, closed medical record review was initiated for Resident 20. Resident 20 was discharged from the facility on 3/13/23. Review of Resident 20's closed medical record showed the contact information about the Developmental Disabilities Agency was not provided to Resident 20's responsible party. On 3/23/23 at 1538 hours, an interview with the Case Manager was conducted. The Case Manger verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 2 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 11 final sampled residents (Resident 472) received an accurate assessment. Residents Affected - Few * Resident 472 had a sacrum Stage 2 pressure ulcer (a localized damage to the skin with partial thickness loss of skin over a bony prominence or related to a medical or other device). However, the MDS comprehensive assessment dated [DATE], showed the resident had no pressure ulcer/injury, a scar over bony prominence, or non-removable dressing/device. Also, the resident was coded for isolation or quarantine for active infectious disease. However, Resident 472 was sharing a room with two other residents. This failure had the potential of not meeting the resident's care needs. Findings: According to the Long-Term Care Facility Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 showed it is important to note that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The document also showed Section O: Special Treatments, Procedures, and Programs, O0100M, Isolation for active infectious disease (does not include standard precautions) is coded only when the resident requires transmission-based precautions and single room isolation (alone in a separate room) because of active infection (i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. Medical record review for Resident 472 was initiated on 3/20/23. Resident 472 was admitted to the facility on [DATE]. a. Review of Resident 472's Pediatric Physical assessment dated 3/11-3/22/23, showed Resident 472 had a Stage 2 pressure ulcer wound to the sacrum. b. Review of the Physician Order Summary Report for March 2023 dated 3/19/23, showed a contact droplet isolation (used to prevent the spread of pathogen that are passed through respiratory secretions) until Viral Respiratory Panel (VRP) (test is designed to detect viral pathogens in the respiratory tract) result. On 3/20/23 at 0920 hours, an observation was conducted. Resident 472 was observed in a room with two other roommates. However, review of Resident 472's MDS comprehensive assessment dated [DATE], showed Resident 472 was assessed/coded with no pressure ulcer/injury, a scar over bony prominence, or non-removable dressing/device; and was assessed/coded to be on isolation or quarantine for active infectious disease. On 3/23/23 at 1029 hours, a medical record review of Resident 472's MDS comprehensive assessment dated [DATE], and concurrent interview was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 472 had a Stage 2 pressure ulcer to the sacrum. The MDS Coordinator stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 3 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 Level of Harm - Minimal harm or potential for actual harm miscoded Section O for the isolation and verified Resident 472 was not alone in the room. The MDS Coordinator further stated it was important to accurately assess the residents to properly customize their plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 4 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 11 final sampled residents (Resident 11) was revised to reflect the resident's current care needs and interventions. This posed the risk of not providing the resident with the individualized and person-centered care. Findings: Review of the facility's P&P titled Care Plan revised 5/2022 showed the plan of care is maintained and updated based upon ongoing patient assessment and the patient's response to care, treatment and services, or at the least weekly. Medical record review for Resident 11 was initiated on 3/20/23. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's MDS dated [DATE], showed Resident 11 had a diagnosis of seizure disorder or epilepsy. Review of the physician's order dated 1/21/22, showed an order for padded side rails for safety and an order dated 2/7/23, for side rails up for seizure precautions. Review of Resident 11's plan of care dated 6/23/22, showed a care plan problem addressing Resident 11's seizure disorder related to partial idiopathic epilepsy. However, the interventions for seizure precautions did not include the padded side rails. On 3/21/23 at 0843 hours, Resident 11 was observed lying in bed with padded side rails present on both sides of the bed. On 3/22/23 at 1333 hours, an interview with RN 3 was conducted. RN 3 stated Resident 11 had side rails with padding implemented on admission due to Resident 11's risk for seizures. On 3/23/23 at 1445 hours, an interview and concurrent medical record review was conducted with RN 2. When asked who was responsible for updating the resident's care plans, RN 2 stated the RNs were in charge of updating the residents' plan of care. RN 2 stated the padded side rails should be included in the care plan interventions. RN 2 verified the plan of care should have been updated to reflect Resident 11's padded side rails for safety which were also ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 5 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for one of 11 final sampled residents (Resident 472). Residents Affected - Few * Resident 472 was admitted to the facility on [DATE], and was assessed to have intact skin. Resident 472 developed a Stage 2 pressure ulcer to the sacrum (the bottom of the spine and lies between the fifth segment of the lumbar spine and the coccyx) while in the facility on 3/11/23. Resident 472's pressure ulcer on the sacrum was observed completely covered with slough (present as a yellow or white coating in a wound bed, a nonviable tissue) during the wound dressing change observation on 3/23/23. There was no documentation to show Resident 472's pressure ulcer wound was reassessed for improvement, deterioration, or effectiveness of the treatment orders nor did the facility accurately assess and document the location and stage of Resident 472's wound. This failure had the potential for Resident 472 to not receive the appropriate wound treatment. Findings: Review of the facility's P&P titled Pressure Injury Overview revised 5/2022 showed pressure ulcer/injury (PU/PI) refers to localized damaged to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Pressure ulcer/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature, moisture, nutrition, perfusion, co-morbidities and condition of soft tissue. Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitoring or evaluation of the impact of the interventions; or revision of the interventions as appropriate. Slough is non-viable yellow, tan, gray, green, or brown tissue; usually moist; can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Review of the National Pressure Injury Advisory Panel (NPIAP) dated 2016 defines the pressure ulcer stages as follows: - Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. - Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 6 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm - Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Residents Affected - Few - Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the NPIAP's Prevention and Treatment of Pressure Ulcers: Quick Refence Guide dated 2014 showed comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as describe in this section of the guideline as follows: - Complete a comprehensive assessment of individual with a pressure ulcer. An initial assessment includes: values and goals of care of the individual and/or the individual's representative; a complete health/medical and social history; a focused physical examination that includes factors that may affect healing, vascular assessment in the case of extremity ulcers, and laboratory tests and x-rays as needed; nutrition; pain related to pressure ulcers; risk for developing additional pressure ulcers; psychological health, behaviors, and cognition; functional capacity; the employment of pressure relieving and redistributing maneuvers; knowledge and belief about prevention and management plan. - Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition. Expect some signs of pressure ulcer healing within two weeks. Adjust expectation for healing in the presence of multiple factors that impair wound healing. - Assess the pressure ulcer initially and reassess it at least weekly. Document the result of all wound assessment. - With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection or other complication). - Assess and document physical characteristics including location, category/stage, size, tissue type, color, peri wound condition, wound edges, undermining, tunneling, exudate, and odor. - Use the finding of a pressure ulcer assessment to plan and document interventions that will best promote healing. Medical record review for Resident 472 was initiated on 3/20/23. Resident was admitted to the facility on [DATE]. Review of Resident 472's MDS dated [DATE], showed Resident 472' s cognitive skills for daily decision making were severely impaired. The MDS comprehensive assessment showed Resident 472 was totally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 7 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dependent on the facility staff for bed mobility, transfers, toileting, and personal hygiene. The document further showed Resident 472 had one unhealed Stage 2 pressure ulcer that was not present upon admission, entry, or reentry. Review of Resident 472's Pediatric Physical assessment dated [DATE], showed Resident 472's sacrum was pink and covered with a Mepilex (self-adherent, multilayer foam dressing designed for use on the sacrum aiming to prevent pressure ulcers) dressing. The document did not show Resident 472 having any pressure ulcers, and the resident was placed on a regular bed and a regular mattress. Review of Resident 472's admission Summary Notes dated 3/9/23, showed Resident 472 had a Mepilex dressing in place at the sacrum. The document also showed the area was slightly pink and had no open skin. Review of Resident 472's Pediatric Physical assessment dated [DATE], showed Resident 472 was assessed to have a Stage 2 pressure injury to the sacrum, measuring 3 cm x 2 cm (length x width). The document also showed Resident 472's sacrum was covered with a Mepilex dressing. However, the same document showed to apply Medihoney (a medication used to support the removal of necrotic tissue and aids in wound healing) to Resident 472's coccyx (a small triangular bone at the base of the spinal column) and cover with a gentle border foam dressing every 72 hours. Review of Resident 472's Order Summary Report for March 2023 showed a physician's order dated 3/11/23, to cleanse Resident 472's wound with normal saline, pat dry with gauze, and apply Medihoney to the coccyx, and cover with a gentle border foam dressing every 72 hours. Review of 472's Treatment Administration Record for March 2023 showed the facility was providing wound care to Resident 472's coccyx every 72 hours as ordered by the physician. Review of Resident 472's plan of care showed a care plan problem dated 3/11/23, addressing Resident 472's impairment to skin integrity of the sacrum. The interventions and tasks included to monitor and document location, size, and treatment of skin injury; and report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician. Review of Resident 472's Progress Notes dated 3/20/23, showed Resident 472 was noted to have a sacral Stage 2 pressure ulcer. The wound was further described to measure 3 cm x 2 cm with pink granulating tissue and with 1 cm x 1 cm slough noted in center of the wound. The wound was noted to have no drainage. The document showed Medihoney was applied and covered with an Optifoam (adhesive foam island dressing that is waterproof). Review of Resident 472's Progress Notes dated 3/21/23, showed Resident 472's pressure ulcer, measuring 3 cm x 2 cm with pink granulating tissue and 1 cm x 1 cm slough in the center of the wound, was cleansed with normal saline. The document further showed Medihoney was applied to Resident 472's coccyx and covered with an Optifoam. Review of Resident 472's Progress Notes dated 3/22/23, showed Resident 472 was provided wound care to the coccyx with no signs and symptoms of infection. Review of Resident 472's Pediatric Physical assessment dated 3/20-3/22/23, showed Resident 472's Stage 2 pressure ulcer to the sacrum, measuring 3 cm x 2cm, was cleansed as per the physician's order. The document noted Resident 472's wound still had a 1 cm x 1 cm slough in the center of the wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 8 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/23/23 at 1051 hours, a wound care observation and concurrent interview was conducted with LVN 5. During wound care observation, Resident 472 was observed to have a circular sacral wound completely covered with slough and measured approximately 3 cm x 2 cm. LVN 5 verified Resident 472's Stage 2 pressure ulcer was at the sacrum, not coccyx. LVN 5 was then asked to describe Resident 472's sacrum wound, LVN 5 stated Resident 472 had a Stage 2 pressure ulcer in the sacrum with some exudate. LVN 5 added when she looked at Resident 472's dressing, it had a small amount of yellow colored drainage and the whole wound bed was covered with slough, and with redness around the border of the wound. LVN 5 was asked how she defined the different stages of the pressure ulcers. LVN 5 stated Stage 1 pressure ulcers would have no open skin; Stage 2 pressure ulcers would have a layer of tissue missing and some slough; Stage 3 pressure ulcer would have muscle tissue exposure; and Stage 4 pressure ulcer would have bone exposure. LVN 5 was asked where she based her definition of stages of pressure ulcers and stated it was how she learned it. LVN 5 was asked if the wound was improving or deteriorating and stated she changed Resident 472's dressing twice and the wound looked the same. On 3/23/23 at 1335 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 did not have a pressure ulcer wound verified for Resident 472 when he was admitted on [DATE]. RN 2 verified Resident 472 developed a Stage 2 pressure ulcer to his sacrum on 3/11/23. RN 2 verified Resident 472's Pediatric Physical assessment dated [DATE], showed a Stage 2 pressure ulcer of sacrum was noted with slough in the center of the wound. RN 2 was asked how she defined a Stage 2 pressure ulcer and stated the skin layer was off and had a little bit of slough. RN 2 was asked what reference she used for the definition of different stages of pressure ulcers and RN 2 took a Medline catalog titled Advanced Wound Care Catalog and referred to page 104 for the Classification of Tissue Destruction in Pressure Injury. Upon reading the definitions of different stages of the pressure ulcers, RN 2 stated Resident 472' s sacral wound should be staged as a Stage 3 pressure ulcer, not Stage 2. RN 2 showed a photograph of Resident's 472's wound to sacrum and verified the wound bed was completely covered with slough, measuring 1.5 cm x 3.0 cm. RN 2 stated she should ask Resident 472's physician to change the wound treatment to be performed more frequently and as needed. RN 2 was asked how the facility determined if Resident 472's wound treatment was effective and if wound improved or worsened. RN 2 stated the communication about assessment between the facility staff and physician. However, there was no documentation to show Resident 472's wound was reassessed weekly for improvement or deterioration or the effectiveness of the wound treatment. On 3/23/23 at 1452 hours, an interview was conducted with the Acting DON. The Acting DON stated she was not aware Resident 472 had a pressure ulcer wound. The Acting DON was asked who was responsible for staging a resident's pressure ulcer wound. She stated she had nine nurses who were wound care certified that could stage the pressure ulcer wounds. The Acting DON verified Resident 472's pressure ulcer wound was not addressed by the IDT. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 9 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 and medical record review, the facility failed to ensure the side rails were padded as ordered for two of 11 sampled residents (Residents 1 and 5). This failure had the potential for injury to the residents. Findings: 1. On 3/20/23 at 1003 hours, Resident 1 was observed with his bilateral full side rails raised, without padding. On 3/21/23 at 1332 hours, Resident 1 was observed in his room on contact precautions with his bilateral full side rails raised, without padding. On 3/21/23 at 1445 hours, concurrent observation and interview was conducted with CNA 3. CNA 3 stated Resident 1 liked spending most of his day in bed and was able to move his right arm a little. On 3/21/23, medical record review for Resident 1 was initiated. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History & Physical examination dated 4/11/21, showed Resident 1 was admitted to the facility with diagnoses including spastic quadriplegic cerebral palsy. Resident 1 had cognitive impairment. Review of Resident 1's March 2023 Order Summary Report showed Resident 1 had an order dated 12/18/20, to have his bilateral side rails padded. On 03/22/23 0820 hours, concurrent interview and observation was conducted with LVN 3 and CNA 1. Resident 1 was observed with his bilateral side rails raised, unpadded. Resident 1 was observed to have tremors of his right leg while he was being repositioned. Resident 1 was observed with redness to his right elbow. On 03/22/23 at 1343 hours, concurrent observation and medical record review was conducted with RN 3. RN 3 verified Resident 1 had an order for padded bilateral side rails. RN 3 verified Resident 1's side rails were not padded. 2. On 03/21/23 at 1348 hours, Resident 5 was observed in bed with her bilateral full side rails raised, no padding. 03/21/23 at 1558 hours, Resident 5 was observed with her bilateral full side rails raised, no padding On 03/21/23 at 1559 hours, an interview was conducted with CNA 1. When asked the reason for Resident 5's side rails, CNA 1 verbalized Resident 5's side rails were to prevent injury in case the resident fell. On 3/21/23, medical record review for Resident 5 was initiated. Resident 5 was readmitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 10 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 facility on [DATE], with diagnosis including convulsions. Level of Harm - Minimal harm or potential for actual harm Review of Resident 5's March 2023 Order Summary Report showed an order dated 5/13/22, for Resident 5 to have padded side rails for seizure precautions every shift. Residents Affected - Few 03/22/23 at 0800 hours, Resident 5 was observed with her bilateral full side rails raised, no padding. 03/22/23 at 1343 hours, a concurrent observation and medical record review was conducted with RN 3. RN 3 verified Resident 5 had an order for padded side rails. RN 3 verified Resident 5's side rails did not have padding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 11 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 3/2022 showed to check the enteral nutrition label against the order before administration. Check the following information: resident's name, ID, and room number; type of formula; date and time formula was prepared. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Medical record review for Resident 13 was initiated on 3/20/23. Resident 13 was admitted [DATE], and readmitted on [DATE]. Review of Resident 13's March 2023 Physician Order Summary Report showed an order dated 3/17/23, to provide Fibersource 1.2 at 60 ml/hr for 20 hours (Ok to use Replete fiber at 60 milliliters per hour or Nutren Fiber 1.0 at 60 ml/hr), and stop feeding at 1000 hours and start feeding again at 1400 hours. Review of Resident 13's Medication Administration Record dated 3/20/23, showed GT feeding at 67 ml/hr continuously for 20 hours (1400-1000) one time a day was initialed at 1400 hours. On 3/20/23 at 0938 hours, Resident 13 was observed sitting up in a wheelchair next to her bed with the GT feeding running. Resident 13 had an undated enteral formula container with approximately 200 ml of formula On 3/20/23 at 0938 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 13's enteral formula container was undated and had no hanging time. LVN 2 stated the enteral formula container must be hang 24 hours and changed every 24 hours, to prevent infection. LVN 2 further stated the noc (night) shift must had hang the enteral formula container. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for GT management for two of 11 final sampled residents (Residents 1 and 13). * The facility failed to ensure Resident 1's GT placement was verified prior to administering the medications via GT. * Resident 13's enteral formula container was undated and with no hanging time. These failures posed the risk for the residents to experience complications related to their GT. Findings: 1. Review of the facility's P&P titled Medication Administration revised April 2022 showed to verify the GT placement prior to administering water flush and medications via GT. On 3/22/23 at 0825 hours, medication administration observation was conducted with LVN 3. LVN 3 prepared Resident 1's medication for the GT administration. LVN 3 was observed with a catheter tipped syringe and had removed the syringe plunger. LVN 3 attached the syringe to Resident 1's GT connecting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 12 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete port and proceeded to administer the Resident 1's medication and water flushes. LVN 3 did not verify the placement of the GT prior to administering Resident 1's medications. On 3/22/23 at 1540 hours, an interview was conducted with LVN 3. LVN 3 stated she would verify the GT placement by checking for gastric residuals. LVN 3 stated she did not verify Resident 1's GT placement prior to administering the resident's medications and she should have checked Resident 1's gastric residuals. Event ID: Facility ID: 555753 If continuation sheet Page 13 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 the trach (tracheostomy) mask and Metaneb (device utilized by the physiotherapist to assist with airway clearance and lung expansion) setup bag and supplies for one of the 11 sampled residents (Resident 6) were labeled in accordance with the facility's P&P. This failure posed the risk for the resident's equipment to be contaminated which had the potential for increased risk of infection. Residents Affected - Few Findings: Review of the facility's P&P titled Changing Respiratory Equipment revised 5/2022 showed: - continuous aerosol therapy equipment will be changed every seven days and as needed, - respiratory disposable treatment equipment will be changed weekly. (HHN equipment, cough assist circuits, aero chambers, etc), and - all disposable equipment will be dated when changed. On 3/20/23 at 1014 and 1224 hours, Resident 6 was observed sitting in the wheelchair connected to cool aerosol via trach mask. Resident 6's trach mask was observed undated and Resident 6's metaneb supply was observed inside an unlabeled plastic bag hanging on the machine with light brown liquid at the bottom of the bag. Medical record review for Resident 6 was initiated on 3/20/23. Resident was admitted to the facility on [DATE]. Review of Resident 6's Order Summary showed the following: - a physician's order dated 6/30/22, to provide metaneb every six hours for mobilization of secretion, - a physician's order dated 2/23/23, to keep the resident on cool mist aerosol via trach mask and titrate FIO2 to keep oxygen saturation level (level of oxygen in the blood) greater than 92%, and - a physician's order dated 6/24/22, to administer albuterol sulfate nebulization solution 2.5 mg (a breathing treatment) per three ml inhale orally via nebulizer every six hours for chronic lung disease. Review of Resident 6's Respiratory Treatment record showed a physician's order dated 3/19/23, to administer acetylcysteine (a medication used to help thin and loosen mucus in the airway) solution 20% two ml inhale orally via nebulizer every six hours for airway clearance. On 3/20/23 at 1224 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 6's trach mask was undated, and the staff would not be able to tell when it was changed. LVN 1 further stated the respiratory supplies were changed by the RT. On 3/20/23 at 1245 hours, a concurrent observation and interview was conducted with RT 2. RT 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 14 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete verified Resident 6's trach mask was undated and unable to tell the date when it was changed. RT 2 further verified Resident 6's metaneb supply and setup bag were undated and had light brown liquid at the bottom of the bag. When asked if the metaneb supply and plastic bag were supposed to be labeled with date when it was changed, RT 2 stated it was not necessary. On 3/23/23 at 1419 hours, a concurrent observation and interview was conducted with the RT Manager. The RT Manager verified Resident 6's trach mask was undated. When asked how often Resident 6's trach mask and metaneb supplies and plastic bag need to be changed, the RT Manager stated weekly and should be dated. Event ID: Facility ID: 555753 If continuation sheet Page 15 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and skill sets needed to care for the residents. * The facility failed to ensure the licensed nurses had the competency to differentiate the stages of pressure ulcers when a resident's pressure ulcer wound was assessed. This failure posed the risk of an adverse outcome to the residents care or services. Findings: Review of the facility's P&P titled Sub-Acute Staff Competency Evaluation Policy revised 10/2022 showed the facility shall ensure the nursing personnel shall be sufficient to assure prompt recognition of any untoward change in patient condition and to facilitate appropriate nursing, medical or other appropriate intervention. On 3/23/23 at 1051 hours, a wound care observation and concurrent interview was conducted with LVN 5. During wound care observation, LVN 5 was asked how she described the resident's sacrum wound and stated, Stage 2 with some exudate when I look at the dressing with small amount of yellow colored drainage, whole wound bed covered with slough, and redness around the border of the wound. LVN 5 was asked how she defined the different stages of the pressure ulcers. LVN 5 stated for Stage 1, there would be no open skin; Stage 2, there would be a layer of tissue missing and some slough; Stage 3, there would be muscle tissue exposure; and Stage 4, there would be bone exposure. LVN 5 was asked where she based her definition of stages of pressure ulcers and stated it was how she learned it. LVN 5 was asked if the wound was improving or deteriorating and stated, I have changed the dressing twice and it looked the same. On 3/23/23 at 1335 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 472 had developed a Stage 2 pressure ulcer to the sacrum on 3/11/23. RN 2 verified Resident 472's Pediatric Physical assessment dated [DATE], showed the sacrum Stage 2 pressure ulcer was noted with slough in the center of the wound. RN 2 was asked how she defined a Stage 2 pressure ulcer and stated the skin layer was off and the wound had a little bit of slough. RN 2 was asked what reference she used for the definition of different stages of pressure ulcers and RN 2 showed a Medline catalog titled Advanced Wound Care Catalog and referred to page 104 for the Classification of Tissue Destruction in Pressure Injury. Upon reading the definitions of different stages of the pressure ulcers, RN 2 stated Resident 472 should be staged as Stage 3 pressure ulcer. RN 2 showed a photograph of Resident's 472's sacrum wound and verified the wound bed was completely covered with slough with redness, and the measurement was 1.5 cm x 3.0 cm. RN 2 was asked if the facility provided an in-service (designating or of training given to employees in connection with their work to help them develop skills) on staging of pressure ulcer wounds and stated, I do not remember of having a formal in-service for staging pressure wound. RN 2 stated, I have not staged a pressure ulcer before. RN 2 further stated, we have nine certified wound care nurses that can assess and stage the pressure ulcer wound or call the physician to assess the wound. On 3/23/23 at 1516 hours, an interview was conducted with LVN 5. LVN 5 stated they had not received an in-service for staging a pressure ulcer. LVN 5 stated they did not have a tool for staging the pressure ulcer. LVN 5 stated they had several wound care specialists or the admitting RN that could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 16 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0726 stage a resident's pressure ulcer wound. Level of Harm - Minimal harm or potential for actual harm On 3/23/23 at 1529 hours, an interview was conducted with the DSD. The DSD stated, I have not done an in-service for pressure ulcers. The DSD stated they had in-service on ways to prevent skin breakdown, but not for staging a pressure ulcer. The DSD further stated, I did not know Resident 472 had a wound. The DSD stated she did not know Resident 472 had a wound and was asked by a nurse to stage it. The DSD further stated she did not knew their nurses could stage a pressure ulcer wound. Residents Affected - Few On 3/23/23 at 1705 hours, an interview was conducted with the Acting DON. The Acting DON was asked if the facility provided an in-service for staging pressure ulcer and stated whatever the DSD had provided was what she had done for the in-services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 17 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 2 was initiated on 3/20/23. Resident 2 was admitted to the facility on [DATE]. Residents Affected - Few Review of the facility's Medication Regimen Review for February 2023 showed a pharmacy recommendation dated 2/28/23, showing Resident 2 was on multiple eye drops and the recommendation was to add instructions to all eye drop orders to wait at least five to 10 minutes between each drop. Review of Resident 2's Order Summary Report showed the following physician's orders dated: - 4/8/22, to administer dextran 70-hypromellose solution 0.1-0.3% (medication to relieve dry, irritated eyes) instill one drop to both eyes every two hours for dry eyes while awake; - 6/3/22, to administer artificial tears ointment (medication to soothe discomfort caused by dry eyes) instill 0.25 mg inch to both eyes every six hours for dry eyes; and -10/14/22, to administer refresh plus solution (medication used to moisten and soothe dry irritated eyes) instill one drop in both eyes every four hours for dry eyes. On 3/23/23 at 1431 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified Resident 2 had multiple eye drop medications and Resident 2's eye drop orders did not show to wait at least five to 10 minutes between each drop. On 3/23/23 at 1433 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 acknowledge the pharmacist's recommendation to add instruction to wait at least five to 10 minutes between each drop. RN 2 verified there was no documentation to address Resident 2's MRR recommendation and there were no changes in Resident 2's eye drop medication orders. Based on interview, record review, facility document review, and facility P&P review, the facility failed to ensure the pharmacist's recommendation was acted upon for two of 11 final sampled residents (Residents 2 and 8). * The facility failed to follow the recommendation to spell out 'sz' to seizure (a sudden uncontrolled burst of electrical activity in the brain) for Resident 8's physician's order for Clobazam (a medication used to help control seizures). This failure had the potential for incorrectly translating the abbreviated reason for administering a medication. * The facility failed to ensure the pharmacist's MRR recommendation for Resident 2's multiple eye drop medications was acted upon. This failure posed the risk of decreased absorption and/or drug interactions between medications. Findings: Review of the facility's P&P titled Pharmacy Services of Nursing Facilities updated on 8/22 showed recommendations are acted upon and documented by the facility staff and or the prescriber. 1. Review of the facility's Medication Regimen Review for February 2023 showed a pharmacist's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 18 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0756 recommendation dated 2/28/23, to spell out 'sz' to 'seizure' for Resident 8's physician's order for Clobazam. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 8 was initiated on 3/20/23. Resident 8 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 8's Order Summary Report showed a physician's order dated 2/6/23, to administer 17.5 mg of Clobazam oral suspension via GT two times a day for 'sz' prevention. Further review of the medical record failed to show documentation the facility followed the pharmacist's recommendation for Resident 8's Clobazam order. On 3/23/23 at 1402 hours, an interview was conducted with RN 2. RN 2 verified that pharmacy drug regimen recommendation dated 2/28/23, was not carried out. On 3/23/23 at 1553 hours, an interview was conducted with the CEO. The CEO stated the Nurse Manager should have carried out the pharmacist's recommendations and updated 'sz' to seizure in Resident 8's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 19 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 472) for unnecessary medication review was free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure the physician's order for PRN lorazepam (a medication to treat anxiety) was limited to a 14-day duration for Resident 472. In addition, the facility failed to ensure Resident 472's behaviors were monitored for the use of lorazepam. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use revised 5/2022 showed the resident's need for the psychotropic medication shall be monitored, as well as when the resident received optional benefits from the medication and when the medication dose can be lowered or discontinued. PRN (as needed) orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days based on an evaluation of the resident for the appropriateness of that medication. The physician shall document the rationale in the resident's medical record and indicate the duration for the PRN order. Medical record review for Resident 472 was initiated on 3/20/23. Resident 472 was admitted on [DATE]. Review of Resident 472's Order Summary Report showed a physician's order dated 3/11/23, to administer 1 mg of lorazepam oral concentration 2 mg/ml every six hours PRN via GT for anxiety, neurostorming (rapid breathing, profuse sweating, rigid arm and leg muscles, abnormal posturing) dysautonomia (dysfunction of the nerves that regulate nonvoluntary body functions such as heart rate, blood pressure, and sweating). Review of Resident 472's Medication Administration Record dated March 2023 did not show the PRN lorazepam medication was administered. However, Resident 472's physician's order for lorazepam did not have a stop date to limit use for a 14-day duration and there was no documentation of behaviors to be monitored for episodes of anxiety, neurostorming, or dysautonomia. On 3/22/23 at 1138 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified Resident 472's lorazepam PRN order was not limited to 14 days and behavior monitoring for episodes of anxiety, neurostorming, or dysautonomia were not monitored. LVN 7 stated the PRN orders should have a stop date and monitored behaviors for psychotropic medications. On 3/22/23 at 1522 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the findings above and stated the PRN orders should have the stop dates. The MDS Coordinator further stated the psychotropic medication orders must (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 20 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 include an indication and behaviors and side effects to be monitored. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 21 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was at 5.71%. Residents Affected - Few * RN 1 failed to fully administer full dosage of Culturelle (improves digestion and restore normal flora) medication via GT to one of the 11 sampled residents (Resident 11). * LVN 5 failed to administer full dose of multivitamin (supplement) via GT for one nonsampled resident (Resident 2). These failures created the risk for medication complications and ineffective therapeutic effects to the residents. Findings: Review of the facility's P&P titled Medication Orders and Management dated 3/2001 and revised 2/2022 showed the medication is administered on schedule and as per the order, verifying medication against order. 1. On 3/22/23 at 0838 hours, a medication administration observation for Resident 11 was conducted. Some white residue was observed on the Culturelle labeled cup after RN 8 did the medication administration. On 3/22/23 at 0838 hours, a concurrent interview with RN 8 was conducted. RN 8 verified the presence of residue in the cup labeled as Culturelle. RN 8 stated not all medications had been administered and she should have mixed it more with water. Review of Resident 11's medical record was initiated on 3/20/23. Resident 11 was admitted to the facility on [DATE]. Review of the Order Summary Report for Resident 11 dated 3/1/23, showed a physician's order dated 11/7/22, to administer Culturelle Kids Packet (Lactobacillus Rhamnosus (GG) one packet via GT two times a day. 2. On 3/23/23 at 0833 hours, during a medication administration observation for Resident 2, red particles residue was observed in the cup labeled as MVI (supplement) after LVN 5 did the medication administration. On 3/23/23 at 0905 hours, a concurrent interview with LVN 5 was conducted. LVN 5 was asked about the red residue left in the cup, LVN 5 verified full dose of the MVI was not given to the resident as the red residue were left in the cup. Review of Resident's 2 medical record was initiated on 3/23/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident's 2 order summary report dated 3/1/23, showed a physician's order dated 3/5/23, to administer Pediatric Multiple Vitamins Tablet Chewable one tablet via GT one time a day for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 22 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 supplement. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 23 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Some 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** 9. Review of the facility's P&P titled Medication Storage revised 4/2022 showed medications are stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding, all medications, and other medications, including treatment items, are stored in a locked cabinet or room inaccessible to patients and visitors and medications are accessible only to licensed personnel. On 3/20/23 at 0957 hours, a cart parked outside Room A was observed unlocked and unattended. RT 2 observed walking to the cart, when asked, RT 2 stated it was an RT cart. RT 2 acknowledged the RT cart was unlocked and left unattended. On 3/21/23 at 1533 hours, a cart parked outside Room A was observed unlocked and unattended. RT 4 observed walking to the cart, when asked, RT 4 stated it was an RT cart. The top drawer of the RT cart was observed with breathing treatment medications. RT 4 acknowledged the RT cart was unlocked and left unattended. On 3/23/23 at 0945 hours, a cart parked in front of nurse's station was observed unlocked and unattended. Staff was observed passing by the cart in the hallway. At 0948 hours, RN 2 walked by and pushed the cart lock. When asked, RN 2 stated it was a shared medication cart. RN 2 acknowledged the medication cart was unlocked and left unattended. On 3/23/23 at 1104 hours, a cart parked in the hallway outside the DSD office was observed unlocked and unattended. RT 5 walked towards the cart, when asked, RT 5 stated it was an RT cart. RT 5 acknowledged the cart was unlocked and left unattended. On 3/23/23 at 1125 hours, an interview was conducted with RN 2. When asked regarding the shared medication cart, RN 2 stated the shared cart contained medications for the residents in Rooms B and C. When asked regarding the unlocked medication cart and RT carts, RN 2 stated the medication carts and RT carts should be locked when left unattended. 7. On 3/21/23 at 0859 hours, during a medication storage observation for Medication cart 1 with LVN 3, the following was observed: - In the second drawer, middle slot of the drawer had unopened Aquaphor topical ointment together with MiraLax powder (treat occasional constipation) of GT administration. Right slot of the drawer contained MVI liquid (supplement), Pepcid liquid (heartburn), Aquaphor topical ointment (to treat dry skin), 1 liter bag of sodium chloride (source of electrolytes and water for hydration), and Aquaphor for lips. - The bottom drawer had prune juice with the expiration of 2/21/23. On 3/21/23 at 0911 hours, a concurrent interview with LVN 3 was conducted. LVN 3 verified the oral medications should be separated from topical and intravenous fluids. On 3/21/23 at 0911 hours, LVN 3 verified the expired prune juice should have been discarded. The prune juice should have been stored in the fridge and not in a drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 24 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 8. On 3/21/23 at 0920 hours, a medication storage observation for Medication Cart 2 with concurrent interview with LVN 5 was condocted. The second drawer of the medication cart had Scopolamine transdermal stored with the following PO (oral administration) medications: - risperidone 0.25 mg (antipsychotic medication) Residents Affected - Some - Creon 12,000 U (used to treat people who cannot digest food normally) - sodium bicarbonate 650 mg (used to relieve heartburn and acid digestion) - acetaminophen Liquid (analgesic) - sucralfate (used to treat stomach ulcers) - diphenhydramine (used to relieves itchiness or rash) - milk of magnesia (used treats constipation) - ibuprofen (used to treat pain) On 3/21/23 at 0934 hours, an interview was conducted with LVN 5. LVN 5 verified the medications with different route of administration should not be mixed or stored together. Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure the medications administered orally were stored separate from the externally used medications in Medication Cart 3. This failure posed the risk for medication errors. * The facility failed to ensure the proper storage of liquid medication in Medication Cart 3. The sticky residue was present on a liquid medication bottle for Resident 19. This failure posed the risk for cross-contamination of the medications. * The facility failed to dispose of the expired, discontinued, and discharged medications and supplies in Medication room [ROOM NUMBER]. This failure had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure an opened vial of lidocaine in the medication fridge inside Med room [ROOM NUMBER] was properly labeled and disposed of. This failure had the potential for the medications to be accidentally administered to another resident and/or diverted. * The facility failed to ensure the narcotic medications were safely stored and accounted for. This failure posed for risk of unauthorized access and/or drug diversion. * The facility failed to store the medications in a safe manner when the medications and RT carts were left unattended. This failure post the risk for non-licensed staff and visitors to have access to the medications. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 25 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Some According to California Code of Regulations, Title 22, Section 72357 - Pharmaceutical Service - Labeling and Storage of Drugs, test reagents, germicides, disinfectants and other household substances shall be stored separately from drugs and shall not be accessible to patients. External use drugs in liquid, tablet, capsule or powder form shall be store separately from drugs for internal use. Review of the facility's P&P titled Medication Storage revised 4/2022 showed it is the policy of this facility to uphold all local, state, and federal laws pertaining to the storage and destruction of medications used in this facility. Discontinued medications will be marked to indicate that the medication has been discontinued and will be disposed, discontinued medications containers will be marked to indicate that the medication has been discontinued and will be disposed. Review of the facility's P&P titled Discarding Destroying Meds revised 6/2022 showed all unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. 1. On 3/21/23 at 0852 hours, an inspection of Medication Cart 3 and concurrent interview was conducted with LVN 2. Medication Cart 3 had four drawers. The following was observed: a. Drawer 1 had supplies including needleless syringes, a pill cutter, tubes for blood, and alcohol pads. b. Drawer 2 had three compartments, and the following was identified: - The first compartment had two sections which stored medications for Resident 19. The first section stored a bottle of Polyvisol liquid (a multivitamin supplement) and a bottle of FE-Vite Iron Drops (an iron supplement). The second section stored a container of glycerin suppositories (a laxative used to relieve constipation which is inserted rectally), a tube of Desitin ointment (an ointment used to treat skin irritation), a Desitin ointment inside its packaging, a container of Aquaphor ointment, and a tube of intensive skin therapy ointment which were stored together with a bottle of liquid Children's ibuprofen (nonsteroidal anti-inflammatory medication) and a bottle of acetaminophen liquid (analgesic). - The second compartment had two sections which stored medications for Resident 13. The first section stored bubble packs (a package of individually sealed tablets in which an individual pushes the medication through the foil to take the medication), a sealed bottle of vitamin D3 liquid and a bottle of famotidine liquid (a medication used to prevent indigestion) together with a container of Aquaphor ointment. The second section stored bisacodyl suppositories (a laxative used to relieve constipation which is inserted rectally) in a clear plastic bag together with a bottle of Viokace (Pancrilipase) tablets (a medication used to aid with food digestion), multiple packets of Polyethylene Glycol powder (an oral laxative), and an unopened bottle of Ibuprofen liquid. - The third compartment had two sections which stored medications for Resident 17. The first section stored bubble packs, a bottle of docusate sodium liquid (a stool softener), a bottle of Glycopyrrolate liquid (reduces excessive saliva and/or secretions), a bottle of Levetiracetam liquid (used to treat seizures), a bottle of acetaminophen liquid, a sealed bottle of Chlorhexidine Gluconate oral rinse (a mouthwash which reduces bacteria growth in the mouth), Floranex tablets (a probiotic), and a sealed bottle of Senna liquid syrup (an oral laxative) together with a box of Enoxaparin syringes (used to treat and/or prevent blood clots), bisacodyl suppositories in a clear plastic bag, and a container for Aquaphor ointment. The second section stored a bubble pack of Ondansetron (used for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 26 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 prevention of nausea and vomiting) tablets. Level of Harm - Minimal harm or potential for actual harm c. Drawer 3 had three compartments, and the following was identified: Residents Affected - Some - The first compartment stored several sealed bags of Sodium Chloride IV solution, 3 sealed vials of Ertapenem powder (an antibiotic), and normal saline syringe flushes in a clear plastic bag for Resident 1. Additionally, a box of Enoxaparin (anticoagulant) syringes and a box of Metamucil powder (a fiber laxative) for Resident 17 was observed in the first compartment together. - The second compartment stored medications for Resident 1, including a container of Beneprotein protein powder, a bottle of Flintstone Multivitamins, a bottle of Simethicone drops (used to relieve bloating caused by excess gas in the stomach and intestines), a bottle of polyethylene glycol powder, famotidine tablets, a bottle of diphenhydramine liquid (medication used to treat allergy symptoms), a bottle of Artificial Tears eyedrops, a tube of Boudreaux's Buttpaste (diaper rash ointment), Aquaphor healing cream, Aquaphor diaper rash cream, Calzamine Skin Protectant Paste, a tube of Nystatin ointment (an antifungal ointment), a box containing a fleet enema (a liquid medication that is inserted rectally in order to relieve constipation), two clear plastic bags of bisacodyl suppositories, a container of Aquaphor ointment, and a box of Mepilex skin barrier borders. - The third compartment had three sections storing Resident 1's medications. The first and second sections contained the medication bubble packs. The third section stored a box containing an Epinephrine syringe (a medication used to treat severe allergic reactions) together with a box of A&D ointment (a skin barrier ointment containing vitamins). d. Drawer 4, in the first compartment, there were supplies, including two sealed packages of urinary catheters, oral syringes, and enteral feed connectors stored together with a sealed container of Beneprotein protein powder. LVN 2 verified the above findings. LVN 2 acknowledged she was not aware of external and internal use medications needed to be stored separately. On 3/21/23 at 0942 hours, an interview was conducted with the Acting DON. The Acting DON stated there were no separate IV or treatment carts, and the treatments and IVs were kept in the same cart. On 3/23/23 at 1634 hours, a follow-up interview was conducted with the Acting DON. The Acting DON verified the internal and external medications should not be stored together. 2. On 3/21/23 at 0852 hours, an inspection of Medication Cart 3 and concurrent interview was conducted with LVN 2. Medication Cart 3 had four drawers. In the second drawer, a bottle of FE-Vite Iron Drops (an iron supplement) for Resident 19 was observed with a brown sticky residue around the bottle and cap. The medication was observed leaking from the cap which was not secured tightly. LVN 2 stated the expectation for the medications was to make sure the medication bottle was clean, and the cap was on correctly. LVN 2 verified she provided the medication to Resident 19; however, she forgot to put the cap on. 3. On 3/21/23 at 1358 hours, an inspection of Medication room [ROOM NUMBER] and concurrent interview was conducted with LVN 2. The following was observed and verified by LVN 2: - a box of Novofine Autocovers Disposable Safety Needles with a pharmacy label with a discard date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 27 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 of 11/21/22. Level of Harm - Minimal harm or potential for actual harm - one Gastrostomy Feeding Tube with the expiration date of 1/1/23 Residents Affected - Some - a box of Novofine Autocovers Disposable Safety Needles with a pharmacy label with a discard date of 11/9/22. - two Bag of IV Bag adaptors with the expiration date of 4/1/21 - a bottle of Silapap Acetaminophen Liquid with the expiration date of 4/2022 - a 1 liter bag of Potassium Chloride 20 meq IV Solution (an IV solution used prevent or treat low blood levels of potassium) with the expiration date of 7/2022 - a 1 liter bag of 5% Dextrose with normal saline IV Solution (an IV solution which hydrates and provides some glucose) with the expiration date of 9/2022 - a 100 ml bag of normal saline IV Solution with the expiration date of 3/2023 - 13 packages of Nutrisource Fiber Supplement powder with the expiration date of 8/28/22 - a container of Nutrisource Fiber Supplement powder with the opened date of 4/1/22. - eight syringes of 5 ml Heparin lock syringe flushes (a blood thinner that prevents blood clots from forming in IV catheters) with the expiration date of 2/28/23 - two syringes of 5 ml Heparin lock syringe flushes with the expiration date of 10/2022 - six infant nipple covers with the expiration date of 11/1/18 - a basin filled with 50 syringes of 5 ml Normal Saline syringes flushes with the expiration date of 12/31/24, however, no pharmacy label indicating a recommended discard date - a clear plastic bag with ten syringes of 5 ml normal saline syringe flushes for Resident 3 with the expiration date of 10/11/22 A basin filled with medications was observed on the floor of Medication room [ROOM NUMBER]. LVN 2 stated she was instructed to put the medications that were to be discarded in the basin and the RNs would dispose of the medications afterwards. She stated the RNs would dispose of the medications in the pharmacy room; however, the basin had been there for about a week. The following medications were observed in the basin on the floor and verified by LVN 2: - one oral syringe filled with clear liquid, unlabeled - a sealed bottle of Propanolol liquid (used for blood pressure control), a bottle of Sodium Chloride liquid and a bottle of Acetaminophen liquid for Resident 12 - a bottle of docusate sodium liquid and a bottle of glycopyrrolate liquid for Resident 17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 28 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Some - a bottle of levetiracetam liquid, a bottle of vitamin D3 liquid and a tube of Aquaphor Healing Ointment for Resident 13 - a bottle of C-Sod Chloride liquid for Resident 16 - a bottle of First-Omepra liquid (used for heartburn relief), a bottle of C-Flecainide liquid (an antiarrhythmic drug used for irregular heartbeat) and a bottle of C-Sod Chloride liquid for Resident B - two bubble packs of Cyproheptadine tablets (used for relief of allergy symptoms) and a bottle of levetiracetam liquid for Resident C - a tube of Aquaphor Healing Ointment for Resident 1 4. On 3/21/23 at 1508 hours, an observation and concurrent interview was conducted with RN 3. A basin filled with medications was observed on the floor of Medication room [ROOM NUMBER]. RN 3 stated the basin was filled with the medications she needed to waste today and she would waste them daily in their pharmacy room. On 3/22/23 at 1451 hours, an interview with the Acting DON was conducted. The Acting DON verified the basin of medications should not have been on the floor. The Acting DON stated the medications in the basin were discharged medications which needed to be returned to the pharmacy room and destroyed. The Acting DON stated the medications were destroyed on the same day the resident was discharged . The Acting DON stated the nurses were supposed to go to the pharmacy room, cover the label of the medication, pour out the medication into the medication waste container, and then document the waste. 5. On 3/21/23 at 1440 hours, an inspection of Medication room [ROOM NUMBER], concurrent interview, and medical record review was conducted with LVN 2. Upon inspection of the medication fridge, an opened and punctured vial of lidocaine was observed stored with a yellow open date sticker dated 12/24. The vial of lidocaine was observed without a label to indicate which resident it was for or how it should be administered. LVN 2 stated the section where the lidocaine vial was found was for the medications for the RT. LVN 2 then called RT 3 to assist her in Medication room [ROOM NUMBER]. RT 3 stated the lidocaine vial was used for Resident 1; however, she had never given lidocaine to Resident 1. LVN 2 verified there was no current order for Lidocaine for Resident 1. LVN 2 verified there should be a label for every medication so the staff would know for who to administer the medication and what it was for. On 3/21/23 at 1533 hours, a concurrent observation and interview was conducted with RNs 3 and 4. RN 3 verified there was no current order for the Lidocaine to be given to Resident 1. RN 3 stated the Lidocaine was used in December 2022 to administer with antibiotics for Resident 1. She stated the Lidocaine was used to reconstitute with Ceftriaxone (an antibiotic). RN 3 verified the medication should have been labeled with a name, date of birth , and instructions for the medication. Medical record review for Resident 1 was initiated on 3/22/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Recap Report dated 12/1/22 - 12/31/22, showed a physician's order for Ceftriaxone Sodium Powder Inject 1 gram intramuscularly one time a day for possible blood infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 29 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 for three days, may give first dose when available. The start date for the medication showed 12/24/22. An administrative order for the medication showed to discontinue the medication on 12/25/22. Review of Resident 1's MAR dated 12/1/22 - 12/31/22, showed only one administration of Ceftriaxone to Resident 1 on 12/24/22. Residents Affected - Some Review of a communication form dated 3/21/23, from the facility's pharmacy showed for Ceftriaxone 1 GM administered (IM), to reconstitute with Lidocaine 1% Solution and injected. On 3/22/23 at 1327 hours, a follow-up interview and medical record review was conducted with RN 3. RN 3 stated the Lidocaine and Ceftriaxone were a one time order for Resident 1. RN 3 verified the Lidocaine vial should have been wasted with the rest of Resident 1's Ceftriaxone medication. RN 3 stated the administration instructions for the Lidocaine from the pharmacy were no longer viewable on Resident 1's MAR, therefore, she notified the pharmacy for the instructions on 3/21/23. 6. On 3/23/23 at 1619 hours, a concurrent observation and interview was conducted with the Acting DON. The Acting DON stated the narcotics that were to be destroyed were to be stored in the facility's locked pharmacy room. She stated the pharmacist would come to the facility once a month to destroy the medications and would record it in their narcotic record. The Acting DON then walked to the pharmacy room and requested RN 7 to open the pharmacy room. RN 7 was observed punching a number sequence into the door's lock pad. The Acting DON stated only RNs and the pharmacist had access to the pharmacy room. A locked four drawer file cabinet was observed with a hole cut out inside the first drawer of the cabinet. Upon closer observation, the hole inside the first drawer of the cabinet was large enough for a forearm to fit through it. On 3/23/23 at 1655 hours, an observation, interview, and concurrent facility document review was conducted with the Pharmacist inside the locked pharmacy room. The pharmacist explained once a medication was dropped into the first drawer of the locked file cabinet, the medication should drop into the second drawer of the cabinet. Review of the Controlled Medication Storage Log for Disposal - Drug Room showed a list of medications which should be accounted for in the locked file cabinet until the Pharmacist came to destroy them. The Pharmacist stated when a narcotic needed to be destroyed, the RN would need to drop the medication into the locked file cabinet and then sign the Storage Log for Disposal. The Pharmacist stated her last visit was conducted on 2/24/23. A narcotic reconciliation was conducted with the Pharmacist for the following dates of medications documented on the Storage Log: 2/27, 2/28, 3/1, 3/2, 3/3, undated, 3/6, 3/8, 3/13, 3/17, and 3/19. The following narcotic medications were unaccounted for: - 82 tablets of Oxycodone (used for the relief of severe pain) for Resident 17, documented on 2/28/23 - 2 ml of Clobazam (used to treat seizure disorder) for Resident 11, documented on 3/2/23 - eight syringes of Ativan (used for seizure disorder and/or to treat anxiety) for Resident 12, documented on 3/8/23 One medication was found but was not documented on the Controlled Medication Storage Log: - four syringes of Methadone (used to treat severe pain) for Resident A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 30 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 pharmacist verified the above findings. The pharmacist stated if she found discrepancies, she would notify the DON. The Pharmacist stated the medications have been unaccounted for in the past but was unable to state how often it occurred. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 31 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and facility document review, the facility failed to ensure a qualified individual was responsible to oversee the day-to-day food operations when: Residents Affected - Few * The dietary cook did not possess the qualifications necessary to oversee the day-to-day food service operations. * The RDN did not provide oversight of the food service operations. These failures had the potential for risk of food borne illnesses and compromising nutritional status for one resident that received food prepared in the kitchen. Findings: Review of the facility's CMS 672 Resident Census and Conditions of residents completed by the facility dated 3/20/23, showed one of 19 residents in the facility received food prepared in the kitchen. Review of the facility's document titled [NAME] Kitchen Staff revised 10/2020 showed job responsibilities. The primary purpose of the position is to prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations, established facility policies and procedures and as directed by the Head Cook/ Chef and/or Certified Dietary Manager. Review of the Dietary Cook's certification showed the completion date of 8/9/21, and expired date of 8/9/24, for eFoodHandler Basic Safety Course. Review of the monthly schedule of the dietary staff dated from August 2022 - March 2023 showed the Dietary Manager and Dietary cook had an alternating week schedule. In addition, the monthly schedule showed Wednesday was the day both employees scheduled to work in the facility. 1. On 3/20/23 at 0800 hours, an interview was conducted with the Dietary Cook. The Dietary [NAME] stated she was a full-time employee. The Dietary [NAME] stated the Dietary Manager was not in the facility. The Dietary [NAME] further stated she had alternating schedule with the Dietary Manager, where the Dietary [NAME] would work from Wednesday to Wednesday. Then when the Dietary [NAME] was off for the week, then the Dietary Manager would be at work for the week. The Dietary cook stated Wednesday was the only day she and the Dietary Manager were in the facility. On 3/21/23 at 1434 hours, a telephone interview was conducted with the RDN. The RDN stated she was hired to work fully remote. The RDN stated she was hired November of 2022 and worked 24 hours a week. The RDN further stated she was not currently physically coming in the facility. The RDN stated she did her assessments via virtual or telephone to communicate with the staff, physicians, and residents' families. The RDN verified she did not have direct oversight of the kitchen. On 3/23/23 at 1318 hours, an interview was conducted with the Dietary Manager. The Dietary Manager verified the monthly schedule and alternating work week with the Dietary Cook. The Dietary Manager was asked who supervised the kitchen when she was not in the facility and stated the IP oversaw the kitchen on her days off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 32 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0801 Level of Harm - Minimal harm or potential for actual harm On 3/23/23 at 1323 hours, an interview was conducted with the IP. The IP denied she supervised the kitchen when the Dietary Manager was off work. The IP stated she helped with the organization of the kitchen supplies, refrigerator, and labeling the food. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 33 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a menu system was approved by the RD and implemented. This failure posed the risk of the resident's nutritional needs not being met, which in turn could lead to compromised nutritional status including weight loss, skin breakdown and dehydration. Findings: Review of the facility's CMS 672 Resident Census and Conditions of residents completed by the facility dated 3/20/23, showed one of 19 residents in the facility received food prepared in the kitchen. Review of the facility's P&P titled Therapeutic Diets revised 6/2022 showed the following: - Nutrition Services will provide regular, modified consistency and therapeutic diets to meet nutritional needs of the patient. Residents shall receive portion sizes which are adequate and appropriate for their nutritional needs. - Regular diet will be nutritionally balanced to meet the Recommended Dietary Allowances for required nutrients. A sufficient level of calories will be provided to achieve and maintain an age-appropriate adequate body weight. - Mechanical soft modification in texture and consistency of the regular diet for the resident with difficulty in chewing and swallowing. All foods in regular diet can be included if they are soft enough to be masticated and swallowed easily. Consistencies may be ordered as chopped:-1/4 inch pieces or ground- 1/8 inch pieces. Medical record review for Resident 472 was initiated on 3/20/23. Resident 472 was admitted on [DATE]. Review of Resident 472's Order Summary Report showed a physician's order dated 12/18/20, showed a regular diet, mechanical soft texture, regular consistency minced. Review of Review of Resident 472's tray card showed mechanical soft; drink-water (bottled water); and main dish of chicken teriyaki and side dish of steamed broccoli. On 3/21/23 at 1105 hours, an interview was conducted with the Dietary Manager. The Dietary Manager was asked to provide the facility's weekly menu and corresponding spread diet spreadsheet for Resident 472's lunch tray. However, the Dietary Manager was unable to provide the spreadsheet for the menu. The Dietary Manager instead showed a binder titled Clinical Diet Manual Food and Nutrition Management Services Inc. and stated she referred to a sample daily menu plan for adolescent diet 12-18 years but did not show the breakdown portion or calories of the food that Resident 472 was receiving for lunch. The Dietary Manager stated the RDN communicated to her how many calories the resident should receive, and she would calculate the food calories served to the resident. During the lunch tray line observation on 3/21/23 at 1110 hours, the Dietary [NAME] was observed preparing Resident 472's lunch meal tray. The Dietary [NAME] prepared teriyaki chicken and steamed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 34 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 broccoli. The Dietary [NAME] pulled a bag of cooked chicken breast in the refrigerator. The Dietary [NAME] took one piece of chicken breast and finely chopped the chicken breast. Then, the Dietary [NAME] poured teriyaki sauce over the finely chopped chicken breast without measuring and stated the teriyaki sauce she poured was about one or two ounces. The Dietary [NAME] then scooped the mixed teriyaki chicken in an eight-ounce ladle and place in a disposable container. Then, the Dietary [NAME] prepared the steamed broccoli that was cooked already from the stove in a pan. The Dietary [NAME] finely chopped the steamed broccoli, scooped the steamed broccoli in an eight-ounce ladle and place them next to the chicken teriyaki in the disposable container, and microwave for 45 seconds to reach the food temperature more than 165 degrees Fahrenheit. The Dietary [NAME] verified she did not follow a menu spreadsheet during the tray line observation. On 3/21/23 at 1548, an interview with the RDN was conducted. The RDN was asked if she had observed tray line in person and approved menus and stated she had not been asked by the facility or done those tasks before. The RDN stated she worked remotely full time. The RDN further stated she had done audits for other facilities before and was capable to do oversight of the kitchen. The RDN stated Resident 472 needed 1000 calories to cover his meals for the day. On 3/21/23 at 1435 hours, the Dietary Manager provided a document of an example for meal menu breakdown. The documentation showed, Per RD: total intake for patient is based on a 2000 Cal/per day stated in patient's notes. Meals pulled from US Food Nutrition Labels online. Lunch Teriyaki chicken: Sauce: 2 oz = 90 calories. Chicken: 3 oz = 120 calories Total 210. Broccoli- 5 oz-54 calories. Total meal 264 calories. Therefore, Resident 472 did not receive the recommended daily calories intake as per the RDN. On 3/22/23 at 0945 hours, an interview with the Dietary Manager was conducted. The Dietary Manager verified the Dietary [NAME] needed to follow a menu when preparing the resident's food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 35 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. Residents Affected - Few * The facility failed to ensure the proper hand washing was performed when preparing food. * The facility failed to ensure the outside ice machine drip tray was clean. * The facility failed to ensure labeling and dating of foods in the refrigerator, freezer, and open, dry storage area. * The facility failed to ensure one frying basket and two tray pans were clean. * The facility failed to ensure the cleaning equipment was stored properly. * The facility failed to ensure the QT-40 Hydrion test strips (simple, reliable, and economic means to measure the concentration of Quarternary Sanitizers) had not expired. * The facility failed to ensure the large commercial trash bin was covered. * The facility failed to ensure the kitchen waste was disposed properly. * The facility failed to ensure the disposable dishware were stored in designated area. * The facility failed to ensure food in the designated dry storage area was off the floor. These failures had the potential for foodborne illnesses to the vulnerable residents in the facility. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/20/23, showed one of 19 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022 Section 2-301.14, food employees shall clean their hands before donning gloves to initiate a task that involves working with food. a. On 3/21/23 at 1110 hours during a lunch tray line observation, the Dietary [NAME] was observed preparing Resident 472's lunch meal. The Dietary [NAME] was observed changing gloves five times during food preparation, touching the lid of the trash can, touching the food utensils, and touching the disposable container lid without performing handwashing in between changing gloves. The Dietary [NAME] verified she should wash her hands in between changing gloves. b. On 03/22/23 at 1020 hours, the Dietary [NAME] was observed pushing the trash can lid after doing handwashing, then preparing food. When asked about this incident, the Lead [NAME] could not explain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 36 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Few 2. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact and utensils shall be clean to sight and touch . On 3/21/23 at 1525 hours, an observation and concurrent interview was conducted with the Plant Operations Manager. The Plant Operations Manager verified there were white colored deposits outside the ice machine drip tray. The Plant Operations Manager stated the kitchen staff was responsible for cleaning the outside of the ice machine. On 3/21/23 at 1435 hours, an observation and concurrent interview was conducted with the Dietary Manager. The Dietary Manager verified the white colored substance deposit was outside the ice machine drip tray. The Dietary Manager stated when she wet the area of the white substance deposit, it got taken off. 3. According to the FDA Food Code 2022, Section 3-501.17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: Marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. On 3/21/23 at 0800 hours, during the initial kitchen tour, the following food items were identified: - 3/4 opened bag of [NAME] sauce in the refrigerator was unlabeled and undated; - opened half bag of shredded cheese in the refrigerator was unlabeled and undated; - a large Ziploc bag of frozen steaks in the freezer was unlabeled and undated; and - rice in a clear circular bin in the dry storage area was unlabeled and undated. On 3/21/23 at 0800 hours, during the initial kitchen tour, an interview was conducted with the Dietary Cook. The Dietary [NAME] verified the findings and stated the items should be labeled and dated. 4. According to the USDA Food Code 2022 Section 4-601.11 Equipment, food-contact surfaces, nonfood-contact surfaces and utensils, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. On 3/20/21 at 0800 hours, an observation and concurrent interview was conducted with the Dietary Cook. The Dietary [NAME] stated the fryer basket on top of a clean tray pan was clean. However, the frying basket was observed with yellow crusted residue around the outside portion. Also, two tray pans were observed with yellow brown crusted residue stored in the clean equipment section. The Dietary [NAME] stated she tried to clean the best she could. 5. According to the USDA Food Code 2022 Section 6-501.113, Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: .(B) Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. On 3/20/21 at 0800 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Cook. The broom and dusk pan were in the dry food storage. The Dietary [NAME] stated the broom and dusk pan should not be there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 37 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Few 6. According to the USDA Food Code 2022, Section 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration, concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. On 3/21/23 at 0850 hours, an observation and concurrent interview was conducted with the Dietary Manager for the QT-40 Hydrion test. The Dietary Manager checked the concentration of the dishwasher sanitizer solution and the red bucket sanitizer solution using the paper test strip taken from a QT-40 Hydrion container test strips. The QT-40 Hydrion test strips container had an expiration date of 2/1/21. The Dietary Manager verified the findings and stated test result may be inaccurate and stated she would order new ones. 7. On 3/21/23 at 0800 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Cook. A large commercial trash can was observed open when the Dietary [NAME] was not performing duties of food preparation or dishwashing. The Dietary [NAME] acknowledged the findings and stated the trash can should be close. 8. Review of the facility's P&P titled Sanitation revised 6/2022 showed the kitchen waste that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shell be disposed daily. On 3/21/23 at 0800 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Cook. In the kitchen sink, three containers of clear pitcher were observed filled with used oil. The Dietary [NAME] acknowledged the findings and stated the used oil in the pitcher containers were not supposed to be there. The Dietary [NAME] stated the container contained old used oil was full. 9. Review of the facility's P&P titled Food Receiving and Storage revised 7/2022 showed non-refrigerated foods, disposable dishware and napkins will be stored in designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. On 3/21/23 at 0800 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Cook. A large black trash bag contained full disposable Styrofoam cups were stored under the kitchen sink. The Dietary [NAME] verified the findings and stated the trash bag should not be there and the Styrofoam cups were to be donated. 10. Review of the facility's P&P titled Food Receiving and Storage revised 7/2022 showed food in designated dry storage areas shall be kept off the floor (at least 18 inches) clear of sprinkler heads, sewage/waste disposal pipes and vents. On 3/21/23 at 0800 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Cook. Multiple clear storage containers filled with cartons of nutritional supplements were observed on the floor in the dry storage room. The Dietary [NAME] acknowledged the findings and stated the containers should not be stored on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 38 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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** Based on interview and medical record review, the facility failed to ensure the medical record for one of 11 sampled residents (Resident 472) was complete and accurate. * The facility failed to ensure Resident 472's Informed Consent for Psychotherapeutic was completed to include the psychotropic medication (any drug that affects brain activity associated with mental processes and behavior) name, diagnosis, and behavior manifestations. This had the potential for the resident's care needs not being met as their medical information was incomplete and inaccurate. Findings: Medical record review for Resident 472 was initiated on 3/20/23. Resident 472 was admitted on [DATE]. Review of Resident 472's Order Summary Report showed a physician's order for psychotropic medication dated 3/11/23, to administer 1 mg of lorazepam oral concentration 2 mg/ml every 6 hours PRN via GT for anxiety, neurostorming (rapid breathing, profuse sweating, rigid arm and leg muscles, abnormal posturing) dysautonomia (dysfunction of the nerves that regulate nonvoluntary body functions such as heart rate, blood pressure, and sweating). Review of Resident 472's Informed Consent for Psychotherapeutic failed to show the medication name, diagnosis, and behavior manifestations to complete the form. On 3/22/23 at 0930 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified Resident 472's Informed Consent for Psychotherapeutic was incomplete. The psychotropic medication name, diagnosis, and behavior manifestations were not written in Resident 472's Informed Consent for Psychotherapeutic. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 39 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview, facility document review, and facility P&P review, the facility failed to ensure the QAPI Committee had met at least quarterly to fulfill the committee's responsibilities to identify and correct quality deficiencies effectively. This failure posed the risk of not identifying the problem prone areas and implementing the effective changes to ensure resident safety and quality. Residents Affected - Few Findings: Review of the facility P&P titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership (undated) showed the Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee which reports its findings, actions and results to the Administrator and governing body and the committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time, and location via email at least two business days prior to the meeting. The facility was unable to provide documentation the facility's QAPI committee had met at least quarterly for the year 2022. On 3/23/23 at 1840 hours, a concurrent interview and June 2022 QAPI document review was conducted with the CEO. The CEO stated the QAPI meetings for the year 2022 were held in March and June 2022. The CEO verified the QAPI committee did not meet quarterly in the past year. The last QAPI meeting was conducted on 6/14/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 40 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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** b. On 3/22/23 at 0800 hours, an interview was conducted with CNA 2. When asked about taking Resident 5's temperature, CNA 2 stated he used the rectal thermometer placed inside a lubricated jelly packet located on top of Resident 5's cabinet. According to CNA 2, he always put Resident 5's thermometer inside the lubricated jelly packet because he could not find the thermometer probe cover and was instructed to do this. Residents Affected - Some On 3/23/23 at 0839 hours, an interview was conducted with the IP. The Infection Preventionist was informed about Resident 5's thermometer being kept inside a lubricant jelly packet. When asked about where the residents' rectal thermometers were supposed to be stored, the IP stated they were supposed to be kept inside a clean container. 8. Review of the facility's P&P titled in addition to Standard Precaution, use Droplet Isolation Precautions revised 10/2021 showed use Droplet Precaution for a patient known or suspected to be infected with microorganisms transmitted by droplets. Droplets are classified as large-particle droplet large than 5 um in size that can be generated by the patient during coughing, sneezing, talking, or during performance of procedures. Place patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but no other infection (cohorting). When a private room is not available and cohorting is not achievable, maintain spatial separation of at lest three feet between the infected patient and other patients and visitors. Medical record review for Resident 472 was initiated on 3/20/23. Resident was admitted on [DATE]. Review of the Physician Order Summary Report for March 2023 for Resident 472 dated 3/19/23, showed contact droplet isolation (used to prevent the spread of pathogen that are passed through respiratory secretions) until the Viral Respiratory Panel (VRP) result available. On 3/20/23 at 0920 hours, an observation was conducted. room [ROOM NUMBER] has a signage posted for Contact and Droplet Precaution. Resident 472 was observed in room [ROOM NUMBER] bed C and had two roommates in Beds A and B. On 3/20/23 at 1105 hours, an interview was conducted with the IP. The IP was asked if the room had Contact and Droplet Precaution signage outside resident's door, should the resident in this room have a roommate. The IP stated they only moved a resident to another room if the resident was COVID positive. On 3/20/23 at 1127 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified Resident 472 was on Contact and Droplet Precautions for pending VRP results. The IP stated the precautions were started over the weekend. The IP verified room [ROOM NUMBER] was empty and available for a resident to occupy. After IP reviewed the facility's P&P for Droplet Precaution, the IP verified Resident 472 should be move to a private room. 6. Review of the facility's P&P on Glove Technique/Infection Control updated 02/2023 showed after direct contact with the resident's excretions, gloves should be changed when care of the patient is not completed in order to prevent cross-contamination of body sites, and wash the hands thoroughly after glove use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 41 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Some On 3/22/23 at 0905 hours, during the medication administration observation for Resident 15, RN 1 was observed not to perform hand hygiene and gloves changing after suctioning the resident's tracheostomy site. RN 1 proceeded with GT medication administration using the same gloves right after tracheostomy suctioning. On 3/22/23 at 0950 hours, an interview with RN 1 was conducted. RN 1 verified she should have washed her hands and changed the gloves she used for suctioning before resuming with medication administration via the GT. RN 1 stated gloves were contaminated and may caused infection to the resident. 7. On 3/23/23 at 0833 hours, during the medication observation for Resident 2, LVN 5 was observed to have entered Resident 2's room. LVN 5 entered the room with mask and gloves only. The resident's room had a signage by the door, Enhanced Barrier Precautions. On 3/23/23 at 0905 hours, an interview with LVN 5 was conducted. LVN 5 stated she should have worn gown aside from gloves and mask to prevent infection. LVN 5 further stated she did not wash or sanitized her hands in between changing of gloves. LVN 5 stated she only sanitized hand once during the medication administration task. On 3/22/23 at 1437 hours, an interview with the IP was conducted. The IP stated the staff must perform hand washing every time gloves were taken off as this might contaminate the hands and the gloves were not clean that could transfer bacteria from one body site to the other. Based on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for five of 11 final sampled residents (Residents 2, 5, 11, 15, and 472) and two of eight nonsampled residents (Residents 4 and 15). * The facility failed to ensure the residents' personal items were labeled in a shared restroom between two Residents (Residents 11 and 15). * Resident 15's two IV tubing lines which were infusing into Resident 15's PICC line were on the floor. * The nursing staff failed to wear proper PPE during high-contact care for Resident 15 who was on enhanced isolation precautions. * The nursing staff failed to perform proper hand hygiene during the GT and tracheostomy care for Resident 4. * The facility failed to implement the proper storage practices of Residents 5 and 11's rectal thermometers. * The nursing staff failed to perform hand washing and change gloves after in contact with Resident 15's secretions. * The nursing staff failed to wear the proper PPE and perform hand hygeine while providing care to Resident 2 who was on Enhanced Barrier Protection. * The facility failed to ensure Resident 472 was placed in a private room when on a contact and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 42 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 droplet precaution for pending VRP (viral respiratory panel test is designed to detect viral pathogens in the respiratory tract) result. These failures posed the risk for the transmission of disease-causing microorganisms to the residents in the facility. Residents Affected - Some Findings: 1. On 3/20/23 at 0831 hours, during an initial tour of the facility, two unlabeled basins and two red teether toys were observed on the sink counter in the shared restroom of Residents 11 and 15. On 3/23/23 at 0808 hours, a concurrent observation and interview was conducted with CNA 2 inside the shared restroom of Residents 11 and 15. One unlabeled basin and two red teether toys were observed on the sink counter. CNA 2 verified the above findings and stated he did not know which resident the basin and toys were for. CNA 2 stated the items should have a label with the residents' names. On 3/23/23 at 1437 hours, an interview was conducted with the IP. The IP stated the residents' personal supplies should not be stored in the bathroom. The IP verified the basins should be labeled, and personal items should be stored in the resident's room. The IP stated they would need to throw the unlabeled items away because there was no way of knowing which resident the items were for if it was not labeled. When asked why the items should have been labeled, the IP stated the items could get contaminated with other residents and could possibly spread infection to the other resident. 2. Review of the facility's P&P titled Administration Set/Tubing Changes - IV Therapy dated 3/2022 showed any (IV) tubing that is suspected to have been contaminated or compromised is changed immediately and to place a sterile end cap on the primary and/or secondary intermittent tubing when it is disconnected from the catheter. On 3/20/23 at 1255 hours, Resident 15 was observed in her stroller with her IV tubing on the floor. Two IV tubings lines with two unused IV needless connecting ports were observed on the floor. The two IV tubing lines were both connected to and infusing to Resident 15. The two unused IV needleless connecting ports on Resident 15's IV tubing were observed without green sterile end caps (a disinfecting cap, which is intended to reduce the risk of infection if placed at the needleless connecting ports of IV tubing). On 3/20/23 at 1303 hours, a concurrent observation and interview was conducted with RN 5. RN 5 verified the above findings. RN 5 stated the CNA moved Resident 15 to the stroller and did not check the IV tubing on the ground. RN 5 verified Resident 15 currently had a PICC line infection (peripherally inserted central catheter, a central venous catheter that is inserted through a vein in your arm and passed through to the larger veins near your heart. Complications of the use of PICC lines include bloodstream infections.). RN 5 stated they would usually clip the IV tubing to the crib or somewhere else near the resident. RN 5 verified the unused IV ports needed to have the green end caps. RN 5 stated the IV tubing should be off the floor for infection control. Medical record review for Resident 15 was initiated on 3/20/23. Resident 15 was readmitted to the facility on [DATE], with diagnoses including bloodstream infection due to central venous catheter. On 3/23/23 at 1437 hours, an interview with the IP was conducted. The IP verified the IV tubing should not be touching the floor and that if the IV ports were not being used, they needed to have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 43 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Some green end caps on. The IP stated the floor was dirty, the IV tubing could get contaminated and it created a risk for infection. The IP verified Resident 15 was admitted with a history with infection of her IV line. She stated ideally, if the tubing was found on the floor, the IV tubing should be changed. 3. Review of the facility's P&P titled Enhanced Standard Precautions dated 11/2022 showed along with standard precautions, utilize the use of gowns and gloves for when high-contact patient care activities are indicated. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Standard Precautions include: Providing hygiene and Device care (central line, urinary catheter, feeding tube, tracheostomy/ventilator). On 3/20/23 at 1303 hours, a concurrent observation and interview was conducted with RN 5. RN 5 was observed fixing Resident 15's IV tubing lines so they were not placed on the floor, and placed the green sterile end caps on all the unused IV needleless connecting ports after swabbing all of the sites with alcohol swabs. When asked whether he should be wearing a gown since this resident was on enhanced isolation precautions, RN 5 stated he should be wearing a gown. Medical record review for Resident 15 was initiated on 3/20/23. Resident 15 was readmitted to the facility on [DATE]. Review of the Order Summary Report for Resident 15 showed an order by the physician dated 2/25/23, for enhanced standard precautions for ESBL. On 3/23/23 at 1437 hours, an interview was conducted with the IP. The IP stated for the residents who were on enhanced standard precautions, the staff needed to wear gloves and a gown for high contact care. The IP stated everyone who worked on the residents' devices, GT, tracheostomies, and IVs would need to wear PPE. 4. On 3/20/23 at 0910 hours, during an initial tour of the facility, LVN 4 was observed entering Resident 4's room after donning gloves and a gown. Resident 4 was observed in his stroller, his tracheostomy site was connected to the oxygen tubing and his GT was connected to the GT feeding. Upon entering the room, LVN 4 flushed Resident 4's GT and cleaned around Resident 4's tracheostomy site. LVN 4 then disconnected Resident 4 from both his GT feeding and oxygen tubing and carried Resident 4 into his crib. LVN 4 then reconnected Resident 4's oxygen tubing back to his tracheostomy site. On 3/20/23 at 0917 hours, an interview was conducted with LVN 4. LVN 4 stated he gave Resident 4 a water flush after Resident 4's GT feeding. LVN 4 stated he was transferring Resident 4 back to bed and disconnected Resident 4's GT feeding and oxygen tubing. LVN 4 stated he did not wash his hands between GT care and tracheostomy care and stated he should have washed his hands. On 3/23/23 at 1437 hours, an interview was conducted with the IP. The IP stated the staff should change gloves and wash their hands between GT care and tracheostomy care. 5.a. On 3/20/23 at 0831 hours, during an initial tour of the facility, a rectal thermometer was observed at the side of Resident 11's bed, stored inside an opened package of lubricant. On 3/22/23 at 1143 hours, a concurrent observation and interview was conducted with CNA 2 inside Resident 11's room. A rectal thermometer was again observed at the side of Resident 11's bed, stored inside an opened package of lubricant. CNA 2 verified the above findings. CNA 2 stated he did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 44 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 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 - Some know why the thermometer was stored like that and he did not check Resident 11's temperature rectally that morning. CNA 2 stated the thermometer was supposed to have a cover, but he did not know where it was. He stated after they used the rectal thermometer, they should put it inside the cover. CNA 2 then found the thermometer cover and placed the rectal thermometer with the cover. CNA 2 stated the lubricant was used before using the thermometer and the thermometer was stored inside the packet. CNA 2 stated the lubricant packets should be used one time and then thrown away. On 3/23/23 at 1437 hours, an interview was conducted with the IP. The IP verified the staff should not be storing the rectal thermometers in a lubricant packet. The IP stated the thermometers needed to be cleaned before use every time and again after every use. The IP verified the staff should not reuse the lubricant packet. When asked why the rectal thermometers should not be stored in a lubricant packet, she stated it was a risk for infection to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 45 of 46 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 555753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to ensure the pneumococcal vaccine (a vaccine to protect against infection by pneumococcal bacteria) was administered to one of the 11 sampled residents (Resident 6). This failure put Resident 6 at risk of contracting pneumococcal disease. Residents Affected - Few Findings: Review of the facility's P&P titled Pneumococcal Vaccination dated 4/2022 showed to provide guidelines to ensure that all eligible patients receive the pneumococcal vaccine in a timely manner, all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections, and pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per facility's physician's approved pneumococcal vaccination protocol. Medical record review for Resident 6 was initiated on 3/20/23. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Pneumococcal Vaccine Consent/Declination Form dated 8/14/20, showed Resident 6's responsible party gave permission for the PPV/PCV (type of pneumococcal vaccine) to be administered and received every 5 years while the resident was at the facility. Review of Resident 6's Immunization Records did not show documentation the pneumococcal vaccine was administered to Resident 6. On 3/21/23 at 1440 hours, an interview and concurrent medical record review was conducted with the IP. The IP was shown Resident 6's Pneumococcal Vaccine Consent/Declination Form dated 8/14/20. The IP verified Resident 6's responsible party gave permission for the vaccine to be administered. The IP verified Resident 6's medical record did not show the pneumococcal vaccine was administered. On 3/23/23 at 1053 hours, a follow-up interview was conducted with the IP. When asked regarding Resident 6's pneumococcal vaccination, the IP stated Resident 6's pneumococcal vaccine should have been administered when Resident 6's responsible party consented for the resident to receive it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555753 If continuation sheet Page 46 of 46